Clinical Documentation Specialist - Full time days in Hickory, NC at Frye Regional Medical Center

Date Posted: 4/13/2018

Job Snapshot

Job Description

Frye Regional Medical Center

As a part of Duke LifePoint Healthcare, our community hospital is being supported with more resources than ever before. Duke LifePoint combines Duke University Health System's unparalleled expertise in clinical excellence, quality and patient safety with LifePoint Health's financial resources and extensive operational experience - making our hospital even stronger. 
Duke LifePoint Healthcare's pledge to our hospital and the communities we serve is quality, expertise and commitment.
  • Quality is the cornerstone of Duke LifePoint, and it is the central focus of everything the organization and our hospital strive to achieve. 
  • Duke LifePoint pledges to bring a wealth of expertise and resources to strengthen the already excellent care our hospital delivers. 
  • And, Duke LifePoint's commitment is to work collaboratively with our hospital to make our community healthier by strengthening local healthcare delivery for the future.  
For more information about Duke LifePoint, visit www.dukelifepointhealthcare.com

Job Description for Clinical Documentation Specialist:

  1. Collaborate with physician, physician extender, nurse, case manager, and Health Information Management coder to identify areas for improved physician documentation.
  2. Conducts initial and extended-stay concurrent reviews on all selected admissions and documents findings on worksheets, denoting all key information utilized in the tracing process.
  3. When a need to clarify documentation in the records is identified, individual must utilize assertive communication skills to guide physician, case manager, or other healthcare professionals to make changes as appropriate to clarify documentation.  Must work collaboratively with the healthcare team to facilitate documentation within the medical record that supports patient’s severity of illness and risk of mortality in compliance with all guidelines and requirements.  Follow thru to obtain response to physician queries.
  4. Utilize monitoring tools to track the progress, monitoring reports and data.  Communicate findings with appropriate management staff.  Able to identify areas of focus through report analysis.
  5. Assist in the development of physician query response reports.  Provides education and in-services as necessary to physicians and ancillary staff.

Job Requirements

Must possess a current, valid RN or LPN license or an RHIA, RHIT, or CCS credential.
Minimum of 3 years clinical OR inpatient coding experience in an acute care setting required; 5 years experience strongly preferred.

Equal opportunity and affirmative action employers and are looking for diversity in candidates for employment: Minority/Female/Disabled/Protected Veteran