Clinical Careers Page

Clinical Documentation Specialist II- Full Time Days

Clinical Careers Page(1 month ago)

OnsiteFull TimeMedior$65,032 - $89,106 (estimated)Health Information Management
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About this role

The Clinical Documentation Improvement Specialist at Cape Fear Valley Medical Center works to ensure clinical documentation accurately reflects patient acuity, severity of illness, and risk of mortality to support appropriate coding, quality metrics, and reimbursement. The role involves clarifying documentation with clinicians and interdisciplinary staff and reviewing records to validate DRG-based payer reporting. The specialist helps maintain clinical validity and coding integrity across patient records.

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Required Skills

  • Clinical Documentation
  • Diagnosis Coding
  • DRG Assignment
  • ICD Coding
  • Chart Review
  • Utilization Review
  • Clinical Review
  • Communication
  • Critical Thinking
  • Microsoft Windows

Qualifications

  • Associate Degree Nursing
  • Bachelor Degree Preferred
  • Registered Nurse NC License
  • RN - Board Of Nursing
  • Medical/Osteopathic Doctorate Preferred
Clinical Careers Page

About Clinical Careers Page

capefearvalley.com

Cape Fear Valley Health is a regional health system headquartered in Fayetteville, North Carolina, serving southeastern North Carolina and surrounding communities. With more than 60 years of service, it operates a network of hospitals, outpatient centers, and primary and specialty care services that span pediatrics through geriatrics. The system emphasizes patient-centered, compassionate care and delivers comprehensive services including emergency, inpatient, and preventive care. Cape Fear Valley focuses on community health and accessibility through integrated clinical programs and local facilities.

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