*Who We Are:* People are our passion and purpose. Come work where you are appreciated for who you are not just what you can do. Central Carolina Hospital is a 137-bed acute care hospital with over 100 physicians and more than 500 employees. The hospital offers a wide range of specialties, including cardiology, orthopedics, ophthalmology, general surgery, obstetrics, gynecology, emergency medicine, gastroenterology, hospitalist services, nephrology, hematology, urology, podiatry, pulmonary medicine, and wound care. * **Where We Are*: From sprawling public art, to a robust music scene, to nature so big and beautiful, Sanford has the small-town feel while still offering something for everyone. Our downtown is a hub of excitement and activity offering delights to satisfy the foodies, art lovers, history enthusiasts, and more. * ***Why Choose Us:** · Health (Medical, Dental, Vision) and 401K Benefits for full-time employees · Competitive Paid Time Off / Extended Illness Bank package for full-time employees · Employee Assistance Program – mental, physical, and financial wellness assistance · Tuition Reimbursement/Assistance for qualified applicants · Discounts with local vendors · Opportunities for education and training through partnership with Duke LifePoint Healthcare · And much more… *Position**Summary*: Reviews medical records to ensure accurate, complete, and compliant clinical documentation that reflects the severity of patient conditions and supports appropriate coding and reimbursement. The role collaborates with Providers and Coding teams to issue queries, clarify diagnoses, and improve documentation practices across the continuum of care. *Essential Functions:* 1. Conducts concurrent and retrospective reviews of the medical records to assess the accuracy, completeness, and specificity of clinical documentation. 2. Initiates and writes compliant provider queries to clarify diagnoses, procedures, and clinical indicators when documentation is incomplete or inconsistent. 3. Collaborate with Physicians, advanced practice providers, coding professionals, and other interdisciplinary team members to ensure the integrity of clinical documentation. 4. Educates clinical staff on documentation improvement strategies, coding implications, and regulatory requirements. 5. Tracks, trends, and reports query outcomes and documentation metrics to support quality improvement and compliance initiatives. 6. Maintains current knowledge of ICD-10-CM/PCS, MS-DRG and APR-DRG methodologies, clinical indicators, and payer regulations. 7. Participate in audits, clinical documentation team meetings, and organizational initiatives to improve documentation and data quality. 8. Ensures compliance with all applicable coding guidelines, CMS regulations and hospital policies related to clinical improvement. 9. Other duties as assigned *EEOC Statement:* Central Carolina Hospital is committed to providing Equal Employment Opportunities for all applicants and employees and complies with all applicable laws prohibiting discrimination against any employee or applicant for employment because of color, race, sex, age, religion, national origin, disability, genetic information, gender identity, sexual orientation, veterans' status or any other basis protected by applicable federal, state or local law *Required Education:* Associate's degree is required Bachelor's degree or Master's degree is preferred *Required License:* CDIP or RHIT or CCS or RN in NC or any compact state **Job:** **Please select a valid job field* **Organization:** **Central Carolina Hospital* **Title:** *Clinical Documentation Improvement Specialist* **Location:** *NC-Sanford* **Requisition ID:** *7468-4620*