Clinical Documentation Specialist - RN

Lifepoint Health • Hickory, NC

4d • Remote

About The Position

Frye Regional Medical Center, located in the beautiful foothills of North Carolina, is a 355-bed acute care hospital with an 81-bed Behavioral Health facility and more than 70 primary and specialty care providers. Frye Regional Medical Center employs over 1500 professional and clinical staff. This is a REMOTE opportunity where the RN Clinical Documentation Improvement Specialist will facilitate improvement in the overall quality, completeness, and accuracy of clinical documentation. The ideal candidate will conduct daily concurrent reviews of medical records to identify missing, vague, and/or incomplete diagnoses and procedures, and perform timely follow-up reviews to ensure provider responses to queries. This role involves querying physicians on specificity of procedures and diagnoses based on coding guidelines, clinical expertise, and LifePoint Health query policy, as well as participating in department and facility Quality and Performance initiatives. Maintaining an education record, meeting minimum corporate CEU requirements, and adhering to safety regulations, Code of Conduct, ethics, and customer service standards are also key aspects of this position. The role requires attendance at hospital training and departmental staff meetings.

Requirements

• Associate’s Degree Nursing (ADN): Required and validated by the presence of a current RN license
• Registered Nurse license
• Three years of clinical work experience

Nice To Haves

• Bachelor’s Degree Nursing (BSN)
• Registered Health Information Technician (RHIT)
• Registered Health Information Administrator (RHIA)
• Certified Coding Specialist - Physician-base (CCS-P)
• Certified Coding Specialist (CCS)
• Minimal completion of Level One on the Clinical Ladder Program annually for Full-time nurses.

Responsibilities

• Conducts daily concurrent reviews of medical records to identify missing, vague and/or incomplete diagnoses and procedures.
• Conducts timely follow up reviews of clinical documentation to ensure that issues discussed and issued queries have been answered by providers.
• Queries physicians on specificity of procedures performed and diagnoses based on accepted coding guidelines, clinical expertise and LifePoint Health query policy.
• Participate in department and facility Quality and Performance initiatives.
• Maintains education record and meets minimum corporate CEU requirements.
• Maintains clean work station, follows all safety regulations, Code of Conduct and ethics, customer service, and attends hospital training and departmental staff meetings.

Benefits

• Multiple levels of medical, dental and vision coverage with medical plans starting at just $10 per pay period
• Tailored benefit options for part-time and PRN employees
• Life, accident, critical illness, hospital indemnity insurance
• Short- and long-term disability
• Paid family leave
• Paid time off
• Higher education and certification tuition assistance
• Loan assistance
• 401(k) retirement package and company match
• Mental, physical, and financial wellness programs (free gym memberships, virtual care appointments, mental health services and discount programs)
• Ongoing learning and career advancement opportunities

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree