Clinical Documentation Specialist

Lifepoint Health • Clyde, NC

1d • Onsite

About The Position

Haywood Regional Medical Center is part of Lifepoint Health, a diversified healthcare delivery network with facilities coast to coast. We are driven by a profound commitment to prioritize your well-being so you can provide exceptional care to others. As the Clinical Documentation Specialist, you will review patient medical records to ensure documentation is accurate, complete, and compliant, collaborating with providers to clarify diagnoses and procedures in accordance with coding guidelines and organizational policies. You will also support quality improvement initiatives, maintain required continuing education, and uphold compliance, safety, and professional standards to promote accurate clinical documentation and optimal patient care. In this role, you'll join a team dedicated to making communities healthier. Join us on this meaningful journey where your skills, compassion and dedication will make a remarkable difference in the lives of those we serve.

Requirements

• High School Diploma or equivalent required; combination of education and relevant healthcare experience may be considered.
• Minimum of one (1) year of healthcare-related experience required; experience in clinical documentation, coding, health information management, nursing, utilization review, or case management preferred.
• Knowledge of healthcare documentation, medical terminology, coding practices, and clinical workflows preferred.
• Ability to review medical records and identify opportunities for documentation accuracy, completeness, and compliance.
• Strong communication and collaboration skills with the ability to work effectively with providers, clinical teams, coding professionals, and other stakeholders.
• Strong attention to detail, analytical thinking, and problem-solving skills with the ability to manage multiple priorities.
• Ability to maintain confidentiality, professionalism, and accuracy while working in a fast-paced healthcare environment.

Nice To Haves

• Preferred credentials include RHIT, RHIA, CCS-P, CCS, Registered Nurse (RN), or Licensed Practical Nurse (LPN) in the state of practice.

Responsibilities

• Facilitate improvement in the overall quality, completeness, and accuracy of clinical documentation by collaborating with physicians, case managers, coders, and other members of the healthcare team to ensure medical records accurately reflect patient diagnoses, treatments, and clinical decisions.
• Conduct daily reviews of inpatient medical records to identify missing, unclear, vague, conflicting, or incomplete diagnoses and procedures, and perform timely follow-up reviews to ensure documentation opportunities and provider queries are addressed.
• Utilize clinical and coding knowledge to identify documentation improvement opportunities and support accurate reporting of physician and hospital outcomes in accordance with established guidelines and regulatory requirements.
• Develop and communicate compliant physician queries regarding diagnosis and procedure specificity based on clinical indicators, accepted coding guidelines, organizational policies, and industry best practices.
• Serve as a documentation resource for physicians and healthcare team members by providing guidance, education, and support related to clinical documentation requirements and improvement opportunities.
• Conduct educational sessions and training programs for physicians, clinical staff, coding teams, and other internal stakeholders to promote accurate, complete, and compliant clinical documentation practices.
• Track and trend documentation improvement opportunities, utilize CDI metrics and reports to monitor progress, and support process improvement initiatives that enhance organizational outcomes.
• Prepare and communicate reports related to CDI performance, progress toward goals, operational improvement plans, and compliance with applicable federal, state, and local regulations, while maintaining confidentiality and adhering to HIPAA and organizational standards.

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, and more.
• Life, accident, critical illness, hospital indemnity insurance, short- and long-term disability, paid family leave and paid time off.
• Higher education and certification tuition assistance, loan assistance and 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.
• Health & Fitness Center Access

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED