Registered Nurse (RN) Clinical Documentation Specialist

Lake Cumberland Regional Hospital; Somerset (KY); Hybrid; USD 70,000 - 90,000; Full time

Benefits offered by this job

Medical benefits

PTO

Tuition assistance

401(k)

Job summary

Lake Cumberland Regional Hospital in Somerset, Kentucky, seeks a Clinical Documentation Specialist RN to enhance inpatient documentation quality and accuracy. The role works with physicians, coders, and case managers to capture accurate diagnoses and procedures, guided by ICD-10 guidelines and CMS/IPPS requirements.

A strong nursing background and Kentucky RN licensure are essential. Hybrid work schedule (one week onsite, two weeks remote) with comprehensive benefits and professional growth

Qualifications

• RN: Associate's degree in nursing required; bachelor's degree in nursing preferred.
• Current RN license in state of practice (Kentucky).
• Minimum 5 years of recent acute care nursing experience OR 2 years CCU experience.
• Strong knowledge of ICD-10-CM and DRG assignment in acute care.

Responsibilities

• Improve quality, completeness, and accuracy of clinical documentation.
• Interact with physicians, case managers, coders and health care team to reflect clinical treatment and diagnosis for inpatients.
• Provide guidance and education on documentation guidelines to clinicians.

Skills

Critical thinking

Clinical software

English communication

Skills Competency Checklist

Education

Associate's degree in nursing

Bachelor's degree in nursing (preferred)

Graduate of an accredited school of Nursing

Tools

Clinical software systems

Job description

Clinical Documentation SpecialistRegistered Nurse (RN)

Shifts: Days | Full Time | 7:00-3:30 or 7:30-4:00 or 8:00-4:30. General Office Hours. Hybrid and Remote Rotation – One Week Onsite, two weeks remote, repeated.

Lake 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®.

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

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 – 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

Requirements

• Minimum 5 years of recent acute care nursing experience (e.g., Med/Surg, ICU, Case Management) OR 2 years CCU experience
• Strong knowledge of ICD‑10‑CM and DRG assignment in the acute care setting
• 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.
• Graduate of an accredited school of Nursing

Certifications

• BCLS 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.

Lake Cumberland Regional Hospital is a 295‑bed hospital located in Somerset, Kentucky, and is part of Lifepoint Health, a diversified healthcare delivery network committed to making communities healthier® with acute care, rehabilitation, and behavioral health facilities from coast to coast.

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.