Clinical Documentation Specialist

Lifepoint Health®; Clyde (NC); On-site; USD 65,000 - 90,000; Full time

Benefits offered by this job

Comprehensive Benefits: Medical,Dental

Tuition assistance and loan options

401(k) retirement with company match

Employee Well-being programs

Job summary

Haywood Regional Medical Center, part of Lifepoint Health, is seeking a Clinical Documentation Specialist to review patient records and ensure documentation is accurate, complete and compliant. You will collaborate with providers to clarify diagnoses and procedures in accordance with coding guidelines and organizational policies.

This role supports quality improvement initiatives, maintains required continuing education, and promotes compliance, safety and professional standards to advance

Qualifications

• High School Diploma or equivalent required; combination of education and healthcare experience may be considered.
• Minimum of one year of healthcare-related experience required; experience in clinical documentation, coding, health information management, nursing, utilization review, or case management preferred.
• Preferred credentials include RHIT, RHIA, CCS-P, CCS, Registered Nurse (RN), or Licensed Practical Nurse (LPN) in the state of practice.
• 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 the ability to manage multiple priorities.
• Ability to maintain confidentiality, professionalism, and accuracy while working in a fast-paced healthcare environment.

Responsibilities

• Facilitate improvement in clinical documentation quality through collaboration with physicians, case managers, coders, and other healthcare team members 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.

Skills

Communication skills

Team collaboration

Attention to detail

Analytical thinking

HIPAA compliance

Education

High School Diploma or equivalent

Job description

Haywood Regional Medical Center is part of Lifepoint Health, a diversified healthcare delivery network spanning the United States. We prioritize your well‑being so you can provide exceptional care. As a 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.

How You’ll Contribute

• 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.

Schedule

Full‑Time; Days

Why Join Us

• Comprehensive Benefits: Multiple levels of medical, dental and vision coverage with plans starting at just $10 per pay period, tailored 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.
• Career Growth: Higher education and certification tuition assistance, loan assistance and 401(k) retirement package with 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.
• Health & Fitness Center Access: www.myhaywoodregional.com/locations/haywood-regional-health-fitness-center

What We’re Looking For

• High School Diploma or equivalent required; a 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.
• Preferred credentials include RHIT, RHIA, CCS‑P, CCS, Registered Nurse (RN), or Licensed Practical Nurse (LPN) in the state of practice.
• 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.

More About Haywood Regional Medical Center

HRMC is a 154‑bed acute hospital with 11 multi‑specialty clinics that has been offering exceptional care to the Haywood County community for over 97 years. The campus also houses a 54,000‑square‑foot Health & Fitness Center and a 44,000‑square‑foot Outpatient Care Center, and operates two urgent‑care centers. The hospital has earned an "A" safety grade from The Leapfrog Group, The Joint Commission National Quality Approval, a Screening Center of Excellence with the Lung Cancer Alliance, an accredited Chest Pain Center from the American College of Cardiology, and a Center of Excellence from the Addario Lung Cancer Foundation.

EEOC Statement

Haywood Regional Medical Center is an Equal Opportunity Employer. Haywood Regional Medical is committed to equal employment opportunity for all applicants and employees and complies with all applicable laws prohibiting discrimination and harassment in employment.