Clinical Documentation Specialist

Memorial Physician Practices; Clyde (NC); On-site; USD 65,000 - 90,000; Full time

Benefits offered by this job

Comprehensive Benefits

401(k) retirement plan with match

Tuition assistance for education

Job summary

Haywood Regional Medical Center is seeking a Clinical Documentation Specialist to review patient records for accuracy, completeness and compliance. You will collaborate with providers to clarify diagnoses and procedures according to coding guidelines and organizational policies.

The role supports quality improvement and ongoing education while upholding HIPAA and safety standards. Join a team dedicated to improving community health in Western North Carolina.

Qualifications

• Minimum of 1 year of healthcare-related experience
• Knowledge of medical terminology, coding practices, and clinical workflows preferred
• RHIT/RHIA/CCS-P/CCS or RN/LPN credentials are preferred in the state of practice

Responsibilities

• Facilitate improvement in clinical documentation quality, completeness and accuracy by collaborating with physicians, coders and other team members
• Conduct daily reviews of inpatient records to identify missing or unclear diagnoses and procedures and perform timely follow-up
• Identify documentation improvement opportunities and support accurate reporting of outcomes per guidelines and regulations
• Develop compliant physician queries based on clinical indicators and coding guidelines
• Serve as a documentation resource for physicians and staff with education and guidance on documentation requirements
• Conduct educational sessions for physicians, clinical staff, coding teams and stakeholders to promote compliant documentation
• Track CDI performance using metrics and reports and support process improvement
• Prepare reports related to CDI performance and regulatory compliance while maintaining confidentiality

Skills

Healthcare documentation

Communication

Analytical thinking

Attention to detail

Education

RHIT

RHIA

CCS-P

CCS

RN

LPN

Job description

Your experience matters

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.

More about our team

Join our team at Haywood Regional Medical Center, where a long‑standing tradition of excellence meets a commitment to exceptional patient care. As a leading healthcare provider in Western North Carolina, we offer a comprehensive range of services, including Orthopedics, Spine Services, Cardiology, Emergency Medicine, General Surgery, Women's Care, and Behavioral Health, supported by 11 multi‑specialty physician clinics. Our growing health system also features a modern Outpatient Care Center, Health & Fitness Center, and two urgent care locations, creating a collaborative environment dedicated to improving the health and well‑being of the communities we serve.

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

We believe that investing in our employees is the first step to providing excellent patient care. In addition to your base compensation, this position also offers:

• Comprehensive 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.
• 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.
• Health & Fitness Center Access www.myhaywoodregional.com/locations/haywood-regional-health-fitness-center

What we're looking for

• 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.
• 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.

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.