Clinical Documentation Specialist
About the role
The Clinical Documentation Specialist plays a crucial role in ensuring that patient medical records are accurate, complete, and compliant. This position collaborates with providers to clarify diagnoses and procedures, supports quality improvement initiatives, maintains required continuing education, and upholds compliance, safety, and professional standards.
Responsibilities
- Facilitate improvement in the overall quality, completeness, and accuracy of clinical documentation by collaborating with physicians, case managers, coders, and other members of the healthcare team.
- Conduct daily reviews of inpatient medical records to identify missing, unclear, vague, conflicting, or incomplete diagnoses and procedures, and perform timely follow-up reviews to ensure documentation opportunities and provider queries are addressed.
- Utilize clinical and coding knowledge to identify documentation improvement opportunities and support accurate reporting of physician and hospital outcomes in accordance with established guidelines and regulatory requirements.
- Develop and communicate compliant physician queries regarding diagnosis and procedure specificity based on clinical indicators, accepted coding guidelines, organizational policies, and industry best practices.
- Serve as a documentation resource for physicians and healthcare team members by providing guidance, education, and support related to clinical documentation requirements and improvement opportunities.
- Conduct educational sessions and training programs for physicians, clinical staff, coding teams, and other internal stakeholders to promote accurate, complete, and compliant clinical documentation practices.
- Track and trend documentation improvement opportunities, utilize CDI metrics and reports to monitor progress, and support process improvement initiatives that enhance organizational outcomes.
- Prepare and communicate reports related to CDI performance, progress toward goals, operational improvement plans, and compliance with applicable federal, state, and local regulations, while maintaining confidentiality and adhering to HIPAA and organizational standards.
Requirements
- A high school diploma or equivalent required; combination of education and relevant healthcare experience may be considered.
- Minimum of one (1) year of healthcare-related experience required; experience in clinical documentation, coding, health information management, nursing, utilization review, or case management preferred.
- Preferred credentials include RHIT, RHIA, CCS-P, CCS, Registered Nurse (RN), or Licensed Practical Nurse (LPN) in the state of practice.
- Knowledge of healthcare documentation, medical terminology, coding practices, and clinical workflows preferred.
- Strong communication and collaboration skills with the ability to work effectively with providers, clinical teams, coding professionals, and other stakeholders.
- Strong attention to detail, analytical thinking, and problem-solving skills with the ability to manage multiple priorities.
- Ability to maintain confidentiality, professionalism, and accuracy while working in a fast-paced healthcare environment.
Qualifications
- High School Diploma or equivalent required.
- One (1) year of healthcare-related experience required.
- Preferred credentials include RHIT, RHIA, CCS-P, CCS, Registered Nurse (RN), or Licensed Practical Nurse (LPN).
- Knowledge of healthcare documentation, medical terminology, coding practices, and clinical workflows preferred.
- Strong communication and collaboration skills with the ability to work effectively with providers, clinical teams, coding professionals, and other stakeholders.
- Strong attention to detail, analytical thinking, and problem-solving skills with the ability to manage multiple priorities.
- Ability to maintain confidentiality, professionalism, and accuracy while working in a fast-paced healthcare environment.
Skills
- Strong communication and collaboration skills.
- Attention to detail and analytical thinking.
- Problem-solving skills.
- Confidentiality and professionalism.
- Accuracy in a fast-paced healthcare environment.
Benefits
Comprehensive benefits package including multiple levels of medical, dental, and vision coverage, tailored benefit options for part-time and PRN employees, and more. Financial protection and PTO, higher education and certification tuition assistance, loan assistance, and a 401(k) retirement package with company match. Employee well-being programs, professional development opportunities, and access to a health & fitness center.
Pay
Competitive salary commensurate with experience.
Schedule
Full-Time; Days
EEOC Statement
Haywood Regional Medical Center is an Equal Opportunity Employer. Haywood Regional Medical is committed to Equal Employment Opportunity for all applicants and employees and complies with all applicable laws prohibiting discrimination and harassment in employment.