Clinical Documentation Specialist

Lifepoint Health•Hickory, NC

14h•Remote

About The Position

Frye Regional Medical Center is hiring a remote Clinical Documentation Specialist to facilitate improvement in the quality, completeness, and accuracy of clinical documentation. The role involves concurrent and follow-up medical record reviews, provider queries, and participation in quality initiatives. The specialist also maintains continuing education records and follows workplace safety, conduct, ethics, and customer service standards.

Requirements

Be a licensed Registered Nurse (RN), or, for non-RN candidates, hold one of the following required certifications: RHIT, RHIA, CCS-P, or CCS.
Have a thorough understanding of ICD-10 Official Coding Guidelines for Coding and Reporting and AHA Coding Clinic; HCPCS/CPT coding systems and CPT Assistant and Coding Clinic for HCPCS guidelines; Medicare Outpatient Prospective Payment System (OPPS); and Ambulatory Payment Classification (APC).
Have at least 3 years of clinical work experience.
Be able to work in a fast-paced and stressful environment.

Responsibilities

Conduct daily concurrent reviews of medical records to identify missing, vague, or incomplete diagnoses and procedures.
Conduct timely follow-up reviews to ensure providers have answered discussed documentation issues and queries.
Query physicians regarding the specificity of procedures and diagnoses, based on accepted coding guidelines, clinical expertise, and LifePoint Health query policy.
Participate in department and facility Quality and Performance initiatives.
Maintain an education record and meet minimum corporate continuing education requirements.
Maintain a clean workstation and follow safety regulations, the Code of Conduct, ethics, and customer service standards; attend hospital training and departmental staff meetings.

Benefits

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