Clinical Documentation Specialist

About the role

Frye Regional Medical Center, located in the foothills of North Carolina, is a comprehensive healthcare provider offering 355 beds for acute care, 81 beds for behavioral health, and over 70 primary and specialty care providers. The organization employs approximately 1500 professionals and clinical staff.

Responsibilities

• Facilitates improvement in overall quality, completeness, and accuracy of clinical documentation.
• Daily concurrent reviews of medical records to identify missing, vague, and/or incomplete diagnoses and procedures.
• 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.
• Participates in department and facility Quality and Performance initiatives.
• Maintains education record and meets minimum corporate CEU requirements.
• Maintains a 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

• Licensed as a Registered Nurse (RN) or certified in lieu of RN license as a Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Coding Specialist - Physician-based (CCS-P), or Certified Coding Specialist (CCS).
• Athorough understanding of ICD-10 Official Coding Guidelines for Coding and Reporting, AHA Coding Clinic, HCPCS/CPT coding systems, 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

• 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.
• 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 with 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 committed to Equal Employment Opportunity for all applicants and employees and comply with all applicable laws prohibiting discrimination and harassment in employment.