Responsible for concurrent auditing of medical record documentation to ensure diagnoses and procedures are specific, accurate, and fully reflect the care provided, resource use, and diagnoses treated. Works closely with physicians and clinical staff to improve documentation quality, support appropriate reimbursement, and capture clinical severity. Provides ongoing education and coaching to support timely, complete, and accurate clinical documentation.
Requirements & Qualifications
Education
- Bachelor’s in nursing, or
- Associate’s in nursing, or
- Associate’s in healthcare health information technology/management
Licensure / Certification
- RHIT, RHIA, CDIP, or CCS preferred
Experience
- 2 years of healthcare experience as a Registered Nurse or LPN in an acute care facility
- 2 years of healthcare experience as a Medical Coder in an acute care facility
- Experience as a Clinical Documentation Auditor preferred
Location
North Carolina, US
Employment Type
Full-time
Experience Level
Intermediate Level
Remote work allowed
Yes
Posted
2 months ago