Clinical Documentation Specialist RN
Posted 2 months ago Expired
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Upload Your ResumeAbout 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
About Raleigh General Hospital
Raleigh General is part of Lifepoint Health, a diversified healthcare delivery network with facilities coast to coast. They are a 300 bed facility caring for nearly 13,000 patients each year with over 50,000 being treated in their emergency room.