Clinical Documentation Specialist

Posted Yesterday
Be an Early Applicant
Hickory, NC, USA
In-Office
Mid level
Healthtech
The Role
Review medical records concurrently to identify incomplete or vague documentation; query providers for specificity per coding guidelines; support quality initiatives, maintain education/CEU records, and ensure documentation accuracy.
Summary Generated by Built In

Clinical Documentation Specialist

This is a REMOTE opportunity

Your experience matters:

Frye Regional Medical Center, located in the beautiful foothills of North Carolina is a 355-bed acute care hospital, 81-bed Behavioral Health facility and more than 70 primary and specialty care providers.

Frye Regional Medical Center employs more than 1500 professional and clinical staff. Our medical center is a 355-bed acute care facility which offers a broad array of inpatient and outpatient care. Frye Regional Medical Center provides patients with a full range of services to meet the healthcare needs of our community. We believe our employees are our most valuable assets in accomplishing this goal and we have made great strides to ensure employee satisfaction. If you are passionate about changing lives, we are looking for you!

How you’ll contribute:

Facilitates improvement in overall quality, completeness, and accuracy of clinical documentation.

A Clinical Documentation Specialist who excels in this role:

  • Conducts daily concurrent reviews of 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 issued queries have been answered by providers.
  • Queries physicians on specificity of procedures performed and diagnoses based on accepted coding guidelines, clinical expertise and LifePoint Health query policy.
  • Participate in department and facility Quality and Performance initiatives.
  • Maintains education record and meets minimum corporate CEU requirements.
  • Maintains clean work station, follows all safety regulations, Code of Conduct and ethics, customer service, and attends hospital training and departmental staff meetings.

Qualifications and requirements:

Applicants should be licensed as a Registered Nurse (RN) or have one of the following certifications in lieu of RN license: 

  • Certifications:  Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Coding Specialist - Physician-base (CCS-P), Certified Coding Specialist (CCS) is required for non-RN candidates.
  • Must have thorough understanding of ICD-10 Official Coding Guidelines for Coding and Reporting and AHA Coding Clinic; HCPCS/CPT coding systems and CPT Assistant and Coding Clinic for HCPCS guidelines; Medicare Outpatient Prospective Payment System (OPPS), and Ambulatory Payment Classification (APC).
  • At least 3 years of clinical work experience is required. 
  • Ability to work in a fast-paced and stressful environment. 
     

What we offer:

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

Comprehensive Benefits: Multiple levels of medical, dental and vision coverage with medical plans starting at just $10 per pay period tailored benefit options for part-time and PRN employees, and more.

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.


"We are an Equal Opportunity Employer. We are committed to Equal Employment Opportunity for all applicants and employees and comply with all applicable laws prohibiting discrimination and harassment in employment."

Skills Required

  • Registered Nurse (RN) license OR RHIT, RHIA, CCS-P, or CCS certification (certification required for non-RN candidates)
  • Thorough understanding of ICD-10 Official Coding Guidelines and AHA Coding Clinic
  • Knowledge of HCPCS/CPT coding systems, CPT Assistant, and Coding Clinic for HCPCS guidelines
  • Familiarity with Medicare Outpatient Prospective Payment System (OPPS) and Ambulatory Payment Classification (APC)
  • At least 3 years of clinical work experience
  • Ability to work in a fast-paced and stressful environment
  • Maintain education record and meet corporate CEU requirements
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The Company
HQ: Brentwood, TN
3,590 Employees
Year Founded: 1999

What We Do

LifePoint Health® is a leading healthcare company dedicated to Making Communities Healthier®. Through our subsidiaries, we provide quality inpatient, outpatient and post-acute services close to home. LifePoint owns and operates community hospitals, regional health systems, physician practices, outpatient centers, and post-acute facilities in 29 states. We are the sole community healthcare provider in the majority of the non-urban communities our facilities serve. More information about the Company, which is headquartered in Brentwood, Tennessee, can be found on our website, www.LifePointHealth.net. All references to "LifePoint,"​ "LifePoint Health,"​ or the "Company"​ refer to LifePoint Health, Inc. or its affiliates. PHYSICIAN OPPORTUNITIES To learn more about practice opportunities available at facilities affiliated with LifePoint Health, visit http://www.lifepointgoodlife.com or call 1-866-864-2680. CAREER OPPORTUNITIES To learn more about career opportunities available at facilities affiliated with LifePoint Health, visit http://www.lifepointhealth.net/careers/career-opportunities/

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