Clinical Documentation Specialist: Drive Accurate Dx

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, 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