Clinical Documentation Nurse Registered Nurse (RN)

Lake Cumberland Regional Hospital; Somerset (KY); On-site; USD 65,000 - 90,000; Full time

Benefits offered by this job

Comprehensive benefits

Tuition assistance

Loan assistance

401(k) retirement plan

Paid time off

Job summary

Lake Cumberland Regional Hospital in Somerset, KY is seeking a Clinical Documentation Specialist Registered Nurse (RN) to improve the accuracy and completeness of inpatient medical records. The role involves concurrent chart reviews, physician queries, and collaboration with the health care team to reflect clinical decisions and diagnoses in ICD-10 coding.

The CDI RN will work within standard office hours, focusing on documentation quality, CMS/IPPS guidelines, and provider education while

Qualifications

• RN: Associate's degree required; bachelor's preferred.
• Current RN license in Kentucky.
• BCLS certification required.
• Ability to work with minimal supervision in stressful environments.
• Proficiency with multiple clinical software systems.

Responsibilities

• Conduct daily inpatient record Reviews to identify missing or unclear diagnoses or procedures.
• Query physicians on specificity of procedures and diagnoses per coding guidelines.
• Track opportunities for CDI process improvement using metrics reports.
• Ensure compliance with federal, state, and local regulations; protect patient privacy under HIPAA.
• Collaborate with case management and quality/risk teams to support data-driven improvements.

Skills

Critical thinking

Decisive judgment

English communication

Minimal supervision

Ability to work in high-stress

Education

Associate's degree in nursing

Bachelor's degree in nursing (preferred)

Tools

Clinical software systems

Job description

Clinical Documentation SpecialistRegistered Nurse (RN)Days | Full Time | 7:00-3:30 or 7:30-4:00 or 8:00-4:30 General Office HoursYour experience mattersLake Cumberland Regional Hospital 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.

How you'll contribute

Facilitate improvement in the overall quality, completeness, and accuracy of clinical documentation. Through concurrent interaction with physicians, case managers, coders and other health care team members, the Clinical Documentation Specialist, will strive to ensure comprehensive medical record documentation that reflects the clinical treatment, decisions, and diagnosis for all inpatients. Serving as a resource to all members of the health care team on documentation guidelines, this position will provide guidance and support, as well as assist with education and training related to improving clinical documentation.

Essential Functions

• Conducts daily reviews of inpatient 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 queries left in the medical record have been answered by the provider.
• Utilizes coding and clinical expertise to identify opportunities and ensure the accuracy and completeness of clinical documentation used for measuring and reporting physician and hospital outcomes.
• Queries physicians on specificity of procedures performed and diagnoses based on accepted coding guidelines, clinical expertise and LifePoint Hospitals query policy.
• Tracks and trends specific opportunities for CDI process improvement through the utilization of metrics reports.
• Assumes responsibilities for following compliance guidelines with federal, state, and local regulations within the department.
• Acts as a strong advocate of the CDI program while educating physician, clinical, and other staff on the importance of clinically accurate documentation and the capture of data through ICD-10 coding. Demonstrates understanding of the importance of non-leading queries and communications with providers.
• Reviews clinical issues and identified query response concerns with physician champion/advisors.
• Stays current with requirements of CMS Inpatient Prospective Payment Systems (IPPS), AHA Coding Clinic and Official Guidelines for Coding and Reporting related to ICD-10.
• Works closely with case management, quality management, risk/compliance management, and medical staff to provide data related to key clinical indicators and operational metrics.
• Works in conjunction with the Directors of Quality Improvement and Care Management, medical staff leadership and other health care disciplines to assure effective monitoring and successful completion of identified plans for improvement.
• Safeguards the patient's right to privacy by judiciously protecting information of the patient and medical record as per HIPPA guidelines.

Why Join Us

• Comprehensive Benefits: Multiple levels of medical, dental and vision coverage - tailored benefit options for part-time and PRN employees, and more. Financial Protection & PTO: Life, accident, critical illness, hospital indemnity insurance, short- and long-term disability, paid family leave and paid time off.
• Financial & Career Growth: Higher education and certification tuition assistance, loan assistance and 401(k) retirement package and company match.
• Employee Well-being: Mental, physical, and financial wellness programs (free gym memberships, virtual care appointments, mental health services and discount programs).
• Professional Development: Ongoing learning and career advancement opportunities.
• Clinical Ladder Eligible - increase base pay by completing the clinical ladder levels

What we are looking for

Education: RN: Associate's degree in nursing required; bachelor's degree in nursing preferred.

License: Current RN in state of practice Active Kentucky license (single state or compact) required. If relocating, licensure must be updated to the new Primary State of Residence (PSOR) before employment begins.

CertificationsBCLS is required.

Skills:

• Critical thinking and decisive judgment; ability to work with minimal supervision in stressful environments.
• Proficiency learning/navigating multiple clinical software systems.
• Effective English communication (read, write, speak, and understand).
• Ability to complete the Skills Competency Checklist within 90 days of hire.

More About Lake Cumberland Regional Hospital

Lake Cumberland Regional Hospital is a 295-bed hospital located in Somerset, Kentucky, and is part ofLifepoint Health, a diversified healthcare delivery network committed tomaking communities healthier with acute care, rehabilitation, and behavioral health facilities from coast to coast. From your first day to your next career milestone-your experience matters.

EEOC Statement"Lake Cumberland Regional Hospital is an Equal Opportunity Employer. Lake Cumberland Regional Hospital is committed to Equal Employment Opportunity for all applicants and employees and complies with all applicable laws prohibiting discrimination and harassment in employment."

Lifepoint Health is a leader in community-based care and driven by a mission of Making Communities Healthier. Our diversified healthcare delivery network spans 29 states and includes 63 community hospital campuses, 32 rehabilitation and behavioral health hospitals, and more than 170 additional sites of care across the healthcare continuum, such as acute rehabilitation units, outpatient centers and post-acute care facilities. We believe that success is achieved through talented people. We want to create places where employees want to work, with opportunities to pursue meaningful and satisfying careers that truly make a difference in communities across the country.