North Carolina Licensed Clinical Documentation Specialist

Job Summary

To enhance the quality of medical records, the full-time North Carolina Licensed Clinical Documentation Specialist will facilitate modifications through collaboration with healthcare teams, conduct chart reviews, and provide ongoing education on documentation standards in a remote setting.

Key responsibilities

• Review and modify clinical documentation to ensure accuracy regarding admission reasons, service intensity, and patient conditions
• Conduct timely chart reviews and communicate deficiencies to healthcare providers, ensuring compliance with documentation standards
• Provide education and resources to medical staff on documentation improvement techniques and maintain a database for statistical reporting

Required qualifications

• BSN, PA, NP, or Doctorate degree in a medically related field
• Three years of progressive healthcare experience in an acute care setting
• Prior experience in chart review, case management, or utilization review is preferred
• Currently licensed as a professional nurse, physician assistant, or MD in North Carolina
• CCDS, CCS, or CDIP certification is preferred