Clinical Documentation Specialist RN

About This Role

This role is a vital mission dedicated to making communities healthier by ensuring comprehensive medical record documentation. You will provide exceptional care through your skills, compassion, and dedication, making a remarkable difference in the lives of those served.

Responsibilities

• Ensure comprehensive medical record documentation that reflects the clinical treatment, decisions, and diagnosis for all inpatients through concurrent interaction with physicians, case managers, coders, and other health team members.
• Conduct daily reviews of inpatient medical records to identify missing, vague, and/or incomplete diagnoses and procedures.
• Conduct 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.
• Utilize 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.
• Query physicians on specificity of procedures performed and diagnoses based on accepted coding guidelines, clinical expertise and LifePoint Hospitals query policy.
• Track and trend specific opportunities for CDI process improvement through the utilization of metrics reports.

Requirements

• Valid West Virginia Registered Nurse license
• Associate's degree in nursing

Qualifications

• Associate's degree in nursing is Required. Bachelor's degree in Nursing is preferred.

Nice to Have

• Bachelor's degree in Nursing
• RHIA, RHIT, CCDS, or CDIP certification

Benefits