Clinical Documentation Specialist

Lifepoint Health • Lake Havasu City, AZ

22h

About The Position

The Clinical Documentation Improvement Specialist facilitates improvement in the overall quality, completeness, and accuracy of clinical documentation. The role conducts concurrent and follow-up medical-record reviews, identifies documentation gaps, and queries physicians about the specificity of procedures and diagnoses using accepted coding guidelines, clinical expertise, and Lifepoint Health query policy. The specialist also supports quality and performance initiatives, maintains continuing-education records, follows safety and conduct requirements, and attends hospital training and departmental staff meetings.

The position is with Havasu Regional Medical Center, a 152-bed, Joint Commission-accredited, Medicare-certified hospital serving the Lake Havasu City community. The posting describes the role as an opportunity for an experienced RN or credentialed health-information or coding professional to apply clinical knowledge and critical thinking to documentation quality.

Requirements

• Three years of clinical work experience.
• If an RN, a current license to practice in Arizona.
• Associate's degree in Nursing.
• BCLS certification.

Nice To Haves

• Bachelor's degree in Nursing.
• Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Coding Specialist–Physician-based (CCS-P), or Certified Coding Specialist (CCS) credential.

Responsibilities

• Conduct daily concurrent medical-record reviews to identify missing, vague, or incomplete diagnoses and procedures.
• Conduct timely follow-up reviews to ensure providers have answered documentation issues and queries.
• Query physicians about 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 that meets minimum corporate CEU requirements.
• Maintain a clean workstation and follow safety regulations, the Code of Conduct, ethics, and customer-service expectations.
• Attend hospital training and departmental staff meetings.
• Perform other duties as assigned.

Benefits

• Medical, dental, and vision benefits for full-time employees.
• 401(k) benefits for full-time employees.
• Competitive paid time off and Extended Illness Bank package for full-time employees.
• Employee Assistance Program offering mental, physical, and financial wellness assistance.
• Tuition reimbursement or assistance for qualified applicants.
• Professional development and growth opportunities.

What This Job Offers

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