Job Description

Facility

Cape Fear Valley Medical Center

Location

Fayetteville, North Carolina

Department

Health Information Management

Job Family

Nursing

Work Shift

Days (United States of America)

Summary

Monitors and coordinates CDI Program processes and reviews inpatient medical records for specified payer as directed on admission and throughout hospitalization. Provides education to medical staff, allied health professionals, and hospital ancillary department who document in patients’ medical records. Serves as preceptor and trainer for new hires. Facilitate modifications to clinical documentation through extensive concurrent interaction with physicians, nursing staff, other patient caregivers, and health information management coding staff that support appropriate reimbursement. Ensures that clinical severity is captured for the level of service rendered to all patients with a DRG based payor (Medicare, Medicaid, Champus). Supports timely, accurate, and completed documentation of clinical information used for measuring and reporting physician and medical center outcomes. Educates all members of the patient care team on an ongoing basis.

Major Job Functions

The following is a summary of the major essential functions of this job. The incumbent may perform other duties, both major and minor, that are not mentioned below. In addition, specific functions may change from time to time:

• Oversee and coordinates the CDS specialist processes for daily workflow efficiency
• Serve as new hire preceptor and provides education and training in the role of train-the-trainer
• Review performance reports that track the progress of the CDMP program from the perspective of specialist performance, scheduling, physician response and overall impact of the CDMP program
• Assist in identification of educational needs for the medical staff and other allied health providers through CDIS reviews, team input and program monitoring reports
• Coordinate ongoing education for physicians and mid-level providers on documentation improvement opportunities
• Assist with training internal customers on clinical documentation opportunities, coding, reimbursement issues and performance improvement methodologies
• Identify the most appropriate principal diagnosis and CC’s to accurately reflect severity of illness and risk of mortality (SOI/ROM) in compliance with government regulations
• Facilitate modifications to clinical documentation that support the clinical severity of services rendered to all patients with a DRG base payor (Medicare, Medicaid, Champus) and support appropriate reimbursement
• Confer with physicians to clarify information, obtain needed documentation, present opportunities and education regarding the significance of appropriate documentation needed to support the clinical severity and risk of mortality of the patient
• Reviews charts with Senior Coding Specialist and/or Director CDIP and/or Coding and Statistics if unable to reach agreement with clinical coding specialists
• Other duties as assigned

Minimum Qualifications

The following qualifications, or equivalents, are the minimum requirements necessary to perform the essential functions of this job:

Education and Formal Training

• Associate’s degree in Nursing required
• Bachelor’s degree in Nursing preferred
• Current Registered Nurse licensure in North Carolina or compact/multi-state license required
• CCDS and/or CDIP certification required OR must complete certification within 1 year of hire

Work Experience

• 5 years of clinical experience in inpatient hospital setting required with at least 1 year of critical care experience (ED, ICU, etc) required
• 3 years of ICD-10 inpatient CDI reviewer experience required

Knowledge, Skills, and Abilities Required

• Proficiency in reading, writing, and speaking the English language
• Knowledge of DRG payor issues, documentation opportunities and clinical documentation requirements
• Flexibility with changing workload/assignments
• Positive teamwork/interpersonal relations in dealing with all members of the team (i.e. co-workers, supervisors, physicians, etc.)
• Excellent observation, analytical thinking and problem solving skills
• Good verbal and written communication skills
• Basic knowledge of computers, database management and presentation software
• Ability to work with highly sensitive information and materials where confidentiality is of utmost importance
• Capable of communicating with people from various professions and backgrounds with tact and diplomacy
• Professional, team player, and ability to remain calm under stressful situations

Physical Requirements

• Some light carrying and/or lifting may be required
• Occasional walking may be required to access all areas of the medical center
• Near visual acuity to proofread hand or type written materials
• Reaching, handling, and use of fingers to operate office machinery
• Position may involve skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials
• Must be able to lift 35 pounds

#CFVH-2026

Required Licenses and Certifications

Cape Fear Valley Health System is an Equal Opportunity Employer M/F/Disability/Veteran/Sexual Orientation/Gender Identity