Clinical Documentation Specialist - HIM IP CDI
Raleigh, North Carolina
NP · Inpatient · Acute Care
Posted Jun 27
- Unit
- HIM IP CDI
What the listing says
Role
- On the floor
- No charge shifts · Precepting expected
- Setting
- Hospital
- Accepts
- NP
Ratio not posted. Ask in the interview.
Pay
- Against the board
The median for nursing in North Carolina is $36/hr, across 460 postings. It covers every nursing role in the state, so it is a bearing, not a like-for-like comparison.
About this role
The Clinical Documentation Specialist will be 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. In addition, the Clinical Documentation Specialist will be responsible for educating physicians, non-physician clinicians, nurses, and other staff to facilitate documentation within the medical record that reflects the most accurate severity of illness, expected risk of mortality, hospital acquired conditions, patient safety indicators, hierarchical condition categories, and level of service rendered. This position will report to the Health Care System Supervisor of Clinical Documentation Integrity.
Sourced from a public job board.
Requirements
- Associate's degree in Health Information Management, Nursing or related field
- Successful completion of the Clinical Documentation Specialist Proficiency Test
- AHIMA certification or AAPC certification or ACDIS certification or RN license or LPN license or NP or PA license or MD license
- Three (3) years of inpatient facility medical coding, acute inpatient direct patient care, or inpatient Clinical Documentation Specialist experience
- Strong knowledge of medical record documentation requirements and coding guidelines
- Strong communication skills, both written and verbal
- Effective organizational skills, time management, management of multiple priorities
- Strong critical thinking and sound judgement in decision making
Place
- City
- Raleigh, North Carolina
- Median rent
- $1,572/mo
- Local household income
- $85,395/yr
- Metro price level
- 2% below the national average
rent and tenant-paid utilities · Census ACS 2024
all local households, not nurse pay · Census ACS 2024
Raleigh area index 98.2, where 100 is the national average.
Raleigh blends Southern charm with a thriving healthcare scene anchored by major research hospitals and the Research Triangle. Leafy neighborhoods like Five Points and proximity to NC State give the city a collegiate energy, while nearby greenway trails and a moderate climate make outdoor resets easy between shifts.
Cost figures from U.S. Bureau of Economic Analysis · 2024 metro Regional Price Parities.
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About the employer
UNC Health is a large, inclusive healthcare system with over 40,000 teammates across North Carolina, whose mission is to improve the health and well-being of the unique communities they serve. The system is anchored in the Chapel Hill area as…
Worth asking
We can’t answer these from the listing we have. Good ones to ask a recruiter or in the interview.
- Can you walk me through base pay range and differentials?
- What should I expect for shifts, weekly hours, weekend, holiday, call, and rotation?
- What orientation, preceptor time, and ongoing unit support are included?
- How are patient load, floating, and staffing support handled day to day?