Job Description

Schedule:  Full Time Weekdays.

Location: This is an on-site position located at Raleigh General Hospital.

Your experience matters   

Raleigh General 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 Clinical Documentation Specialist RN, 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   

A Clinical Documentation Specialist RN who excels in this role:

• Ensures comprehensive medical record documentation that reflects the clinical treatment, decisions, and diagnosis for all inpatients through concurrent interaction with physicians, case managers, coders, and other health team members.
• 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.

What we're looking for 
Qualified applicants must have a valid West Virginia Registered Nurse license. Additional requirements include:

• Associate's degree in nursing is Required. 
• Bachelor's degree in Nursing is preferred.
• RHIA, RHIT, CCDS, or CDIP certification is preferred.

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 for full-time and part-time 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 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. 

More about Raleigh General Hospital

People are our passion and purpose. Come work where you are appreciated for who you are not just what you can do. Raleigh General Hospital is a 300 bed facility caring for nearly 13,000 patients each year with over 50,000 being treated in our emergency room. We offer a wide range of surgical services as well as specialty programs including Cardiac CTA, Digital Mammography, and Trauma Services. 

Raleigh General Hospital is committed to providing Equal Employment Opportunities for all applicants and employees and complies with all applicable laws prohibiting discrimination against any employee or applicant for employment because of color, race, sex, age, religion, national origin, disability, genetic information, gender identity, sexual orientation, veterans' status or any other basis protected by applicable federal, state or local law.

Lifepoint Health is a leader in community-based care and driven by a mission of Making Communities Healthier. Our diversified healthcare delivery network spans 29 states and includes 63 community hospital campuses, 32 rehabilitation and behavioral health hospitals, and more than 170 additional sites of care across the healthcare continuum, such as acute rehabilitation units, outpatient centers and post-acute care facilities. We believe that success is achieved through talented people. We want to create places where employees want to work, with opportunities to pursue meaningful and satisfying careers that truly make a difference in communities across the country.

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