North Carolina Licensed Clinical Document Specialist

Job Summary

To enhance the quality of clinical documentation, the part-time North Carolina Licensed Clinical Document Specialist will review medical records, facilitate modifications, and educate healthcare team members while working remotely.

Key responsibilities

• Review clinical documentation and facilitate necessary modifications to ensure accuracy and compliance with regulations
• Communicate deficiencies to healthcare staff and provide ongoing education on documentation improvement techniques
• Compile and document chart findings in a dedicated CDI database for statistical reporting and quality assurance

Required qualifications

• BSN, PA, NP, or Doctorate degree in a medically related field
• Three years of progressive healthcare experience in an acute care setting
• Currently licensed as a Professional Nurse, Physician Assistant, or MD in North Carolina, preferred
• Previous experience in chart review, case management, or utilization review is preferred
• Certifications such as CCDS, CCS, or CDIP are preferred