RN Clinical Documentation Specialist

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

Benefits offered by this job

Medical coverage

Dental coverage

Vision coverage

PTO & leave

Life insurance

Disability insurance

Tuition assistance

401(k)

Job summary

Lake Cumberland Regional Hospital in Somerset, KY, is seeking a Clinical Documentation Specialist Registered Nurse to support accurate inpatient documentation and coding quality. You will conduct daily chart reviews, issue physician queries, and collaborate with care teams to reflect clinical decisions and treatments.

You will work within Lifepoint Health's CDI program, following CMS guidelines and HIPAA privacy standards, while educating staff to improve documentation processes.

Qualifications

• RN with current Kentucky license and state practice.
• Associate degree required; bachelor's degree preferred.
• BCLS certification required.

Responsibilities

• Review inpatient records daily to identify missing, vague, or incomplete diagnoses and procedures.
• Conduct follow-up reviews to ensure queries are answered by the provider.
• Apply coding and clinical expertise to ensure accuracy of clinical documentation.
• Query physicians on procedure and diagnosis specificity per guidelines.
• Track CDI opportunities and report trends using metrics.
• Protect patient privacy in accordance with HIPAA requirements.

Skills

Critical thinking

Clinical software systems

English communication

Querying documentation

Education

Associate's degree in nursing

Bachelor's degree in nursing

Job description

Lake Cumberland Regional Hospital in Somerset, KY, is seeking a Clinical Documentation Specialist Registered Nurse to support accurate inpatient documentation and coding quality. You will conduct daily chart reviews, issue physician queries, and collaborate with care teams to reflect clinical decisions and treatments.

You will work within Lifepoint Health's CDI program, following CMS guidelines and HIPAA privacy standards, while educating staff to improve documentation processes.