Lead Clinical Documentation Specialist

Raleigh General 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 Clinical Documentation Specialist youre embracing a vital mission dedicated to making communities healthier . Join us on this meaningful journey where your skills compassion and dedication will make a remarkable difference in the lives of those we serve.

How youll contribute

The RN or LPNClinical Documentation Specialistwill Facilitate improvement in the overall quality completeness and accuracy of clinical documentation. Through 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. Additional job duties include:

• Conducts 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.
• 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

Schedule:This position is an exempt full time Benefited Onsite position. Working hours are generally Monday through Friday 8am 4:30pm.

What were looking for
Qualified applicants will have a current state RN or LPN/LVN license. Additional requirements include:

• BCLS Certification Required
• 3 years of Clinical documentation experience and Bachelors Degree Preferred
• Previous Leadership experience Preferred
• RHIT and/or RHIA CCDS or CDIP certification preferred
• Requires critical thinking skills decisive judgment and the ability to work with minimal supervision. Must be able to work in a stressful environment and take appropriate action.

Why join us

We believe that investing in our employees is the first step to providing excellent patient addition to your base compensation this position also offers:

• Comprehensive Benefits:Multiple levels of medical dental and vision coverage for full-time andpart-time employees.
• 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.

More about Raleigh General Hospital

People are our passion and purpose. Come work where you are appreciated for who you are not just what you can do. Raleigh General Hospital is a 300 bed facility caring for nearly 13000 patients each year with over 50000 being treated in our emergency room. We offer a wide range of surgical services as well as specialty programs including Cardiac CTA Digital Mammography and Trauma WV is an ideal place to live andboasts many scenic cultural and recreational opportunities. From restaurants and breweries to art galleries and unique attractions Beckley is an outdoor playground with something for all tastes.

Raleigh General Hospital is committed to providing Equal Employment Opportunities for all applicants and employees and complies with all applicable laws prohibiting discrimination against any employee or applicant for employment because of color race sex age religion national origin disability genetic information gender identity sexual orientation veterans status or any other basis protected by applicable federal state or local law.