Clinical Documentation Specialist

Clinical Documentation Specialist

This is a remote opportunity.

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 workstation, 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 an 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.