Registered Nurse (RN) Clinical Documentation Specialist

Clinical Documentation Specialist Registered Nurse (RN)

Days | Full Time | 7:00-3:30 or 7:30-4:00 or 8:00-4:30 General Office Hours

Hybrid and Remote Rotation

One Week Onsite, two weeks remote, repeated

Lake Cumberland Regional 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 Registered Nurse (RN) joining our team, you're 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 you'll contribute

• Facilitate improvement in the overall quality, completeness, and accuracy of clinical documentation.
• Through concurrent 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.

Essential Functions

• Conducts daily 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.
• Assumes responsibilities for following compliance guidelines with federal, state, and local regulations within the department.
• 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 coding. Demonstrates understanding of the importance of non-leading queries and communications with providers.
• Reviews clinical issues and identified query response concerns with physician champion/advisors.
• Stays current with requirements of CMS Inpatient Prospective Payment Systems (IPPS), AHA Coding Clinic and Official Guidelines for Coding and Reporting related to ICD-10.
• Works closely with case management, quality management, risk/compliance management, and medical staff to provide data related to key clinical indicators and operational metrics.
• Works in conjunction with the Directors of Quality Improvement and Care Management, medical staff leadership and other health care disciplines to assure effective monitoring and successful completion of identified plans for improvement.
• Safeguards the patient's right to privacy by judiciously protecting information of the patient and medical record as per HIPPA guidelines.

Why Join Us:

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 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.

What we are looking for:

Requirements:

• Minimum 5 years of recent acute care nursing experience (e.g., Med/Surg, ICU, Case Management) OR 2 years CCU experience
• Strong knowledge of ICD-10-CM and DRG assignment in the acute care setting

Education:

• RN: Associate's degree in nursing required; bachelor's degree in nursing preferred.

License :

• Current RN in state of practice
• Active Kentucky license (single state or compact) required. If relocating, licensure must be updated to the new Primary State of Residence (PSOR) before employment begins.
• Graduate of an accredited school of Nursing

Certifications

• BCLS is required.

Skills:

• Critical thinking and decisive judgment; ability to work with minimal supervision in stressful environments.
• Proficiency learning/navigating multiple clinical software systems.
• Effective English communication (read, write, speak, and understand).
• Ability to complete the Skills Competency Checklist within 90 days of hire.