Summary of Performance Expectations:
Responsible for analyzing and auditing medical records concurrently to ensure that the clinical information within the medical record is specific, accurate, clinical valid, complete, and compliant. Communicates need for improved documentation to providers to assure appropriate reimbursement for services provided and assure evidence-based practice guidelines are followed to maximize reimbursement for value-based purchasing.
Education and Credentials:
Required:
- Graduate of accredited nursing program.
- Current NC RN license or licensure from Nursing Compact State.
- Bachelor’s degree in Nursing.
- Professional Certification in Medical Coding required or obtained within four years of employment or placement into position.
Preferred:
Work Experience:
Required:
Five years of direct clinical nursing experience. Given training and on-the-job experience incumbent should be proficient in the basic aspects of the job within three months of employment date.
Preferred:
Five years experience with a Clinical Documentation Improvement Program. Two years of experience in management.