About WakeMed:
Serving the community since 1961, WakeMed Health & Hospitals is a nationally recognized, private, not-for-profit health care organization founded and based in Raleigh, N.C. The largest health system in Wake County, WakeMed exists to improve the health and well-being of our community by providing outstanding, compassionate, patient- and family-centered care to all. The 919-bed system comprises a network of facilities throughout the Triangle area, delivering health and wellness services that bring added value to the communities we serve. WakeMed is a leader in cardiac and vascular care, women's and children's services, emergency medicine and trauma care, physical rehabilitation, orthopaedics and neurosciences. Specialty facilities include the WakeMed Heart Center, Children's Hospital, Women's Pavilion and Birthplace, Rehabilitation Hospital, Adult and Children's Emergency Departments and a Level 1 Trauma Center. WakeMed's team of more than 9,400 employees, 2,000 volunteers, 1,300 affiliated physicians, and the more than 300 physicians employed by WakeMed Physician Practices use the most advanced technologies along with the best minds and the biggest hearts to ensure the finest quality in health care and community health. For more information, visit www.wakemed.org.

As an Equal Opportunity Employer, WakeMed provides an inclusive work environment that promotes the valuing of differences, respect for people and cooperativeness among our diverse workforce. WakeMed does not discriminate against any employee or applicant in any terms or conditions of employment. All applicants/employees are considered for employment, transfer, promotion or training without regard to race, religion, color, gender, gender identity/expression, genetics, sexual orientation, age, pregnancy, national origin, disability or veteran status.

Position Information:
The Clinical Documentation Integrity Specialist, Sr. is responsible for coordinating the Clinical Documentation team in concurrent reviews of medical record documentation to ensure specificity of diagnoses and procedures reflect the care provided, severity of illness, and conditions treated. Communicates with physicians and physician extenders regarding missing, incomplete, unspecific, unclear, or conflicting documentation. Gathers and analyzes information pertinent to documentation findings and outcomes of communications and shares with management as needed. Works as a pivotal team member with HIM, PFS, Case Management, and Quality Reporting staff to ensure complete and concise documentation is captured in medical records. Daily oversight of workflow, processes, and monitoring all members of the Clinical Documentation Improvement (CDI) team. Maintains staff metrics and provides feedback to management.
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Experience Requirements:
2 Years Clinical - Acute Care Or 2 Years Coding And Diagnosis-Related Group Analysis Required

Education Required:
Bachelor's Degree Health Information Management Or Nursing Or Physician Assistant Required - And Master's Degree Healthcare Or Nursing Preferred

Licensure/Certification Requirements:
Registered Health Information Administrator Or Registered Nurse Or Licensed Physician Assistant Or Registered Health Information Technician Required - And Certified Documentation Improvement Practitioner Or Certified Coding Specialist Preferred

Hours of Work:
5 days/8 hours

Weekend Requirements:
No Weekends

Call Requirements:
None