Registered Nurse (RN), Clinical Documentation Specialist

Lifepoint Health • Clyde, NC

3h • Hybrid

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 a Registered Nurse (RN) joining our team, you’re embracing a
vital mission 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.

The Clinical Documentation Specialist (CDS) will join the health information
management (HIM) team, serving as a link between the clinical and non-clinical
team members. The CDS will be an active member of the multidisciplinary care
giving team. Communication with providers is critical with the CDS assisting
providers to assure complete and accurate documentation in the medical records
to support complete and accurate coding. After training, the position may
become a hybrid role, with both on site and remote shifts.

Requirements

• Applicants should have a current Registered Nurse licensure in the State of North Carolina or from a compact state.
• Associate’s Degree in Nursing (ADN) Required, BSN Preferred
• Three years of clinical work experience required
• Must have 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

Nice To Haves

• BSN Preferred

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.
• Participates in department and facility Quality and Performance initiatives. Participates in the interdisciplinary teams.
• Maintains education record with meets minimum corporate CEU requirements.
• Maintains clean workstation, 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, 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.
• Access to our 54,000 sq. ft. Health and Fitness Center

What This Job Offers

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