RN Clinical Documentation Specialist - Elevate Records

Lake Cumberland Regional Hospital; Somerset (KY); On-site; USD 65,000 - 90,000; Full time

Benefits offered by this job

Comprehensive benefits

Tuition assistance

Loan assistance

401(k) retirement plan

Paid time off

Job summary

Lake Cumberland Regional Hospital in Somerset, KY is seeking a Clinical Documentation Specialist Registered Nurse (RN) to improve the accuracy and completeness of inpatient medical records. The role involves concurrent chart reviews, physician queries, and collaboration with the health care team to reflect clinical decisions and diagnoses in ICD-10 coding.

The CDI RN will work within standard office hours, focusing on documentation quality, CMS/IPPS guidelines, and provider education while

Qualifications

• RN: Associate's degree required; bachelor's preferred.
• Current RN license in Kentucky.
• BCLS certification required.
• Ability to work with minimal supervision in stressful environments.
• Proficiency with multiple clinical software systems.

Responsibilities

• Conduct daily inpatient record Reviews to identify missing or unclear diagnoses or procedures.
• Query physicians on specificity of procedures and diagnoses per coding guidelines.
• Track opportunities for CDI process improvement using metrics reports.
• Ensure compliance with federal, state, and local regulations; protect patient privacy under HIPAA.
• Collaborate with case management and quality/risk teams to support data-driven improvements.

Skills

Critical thinking

Decisive judgment

English communication

Minimal supervision

Ability to work in high-stress

Education

Associate's degree in nursing

Bachelor's degree in nursing (preferred)

Tools

Clinical software systems

Job description

Lake Cumberland Regional Hospital in Somerset, KY is seeking a Clinical Documentation Specialist Registered Nurse (RN) to improve the accuracy and completeness of inpatient medical records. The role involves concurrent chart reviews, physician queries, and collaboration with the health care team to reflect clinical decisions and diagnoses in ICD-10 coding.

The CDI RN will work within standard office hours, focusing on documentation quality, CMS/IPPS guidelines, and provider education while