Registered Nurse, Clinical Documentation Specialist
Lifepoint Health®
full-time
Posted on:
Location Type: Remote
Location: North Carolina • United States
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About the role
- Accurately performs patient assessments and identifies patient needs
- Identifies and initiates appropriate nursing interventions
- Provides care appropriate to condition and age of the patient
- Performs timely and appropriate documentation relating to medical necessity in the medical record
- Responsible for completion and revision of the Interdisciplinary Care Plan for each patient
- Performs timely and accurate QI assessments
- Facilitates improvement in the overall quality, completeness, and accuracy of clinical documentation.
- Conducts daily reviews of inpatient medical records to identify missing, vague, and/or incomplete diagnoses and procedures.
- 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.
- Tracks and trends specific opportunities for CDI process improvement through the utilization of metrics reports.
- Prepares and presents educational programs to all internal constituents related to clinical documentation issues and coordinates same with clinical staff, physicians, compliance, and coding staff.
- Makes regular reports of progress toward goals associated with clinical documentation improvement opportunities and operational improvement plans.
- Participates in data collection to document findings and outcomes to drive quality improvement and improved clinical documentation.
Requirements
- Applicants should have a current state RN license.
- Bachelors degree preferred but not required
- Certifications: RHIA, RHIT preferred
- CCDS or CDIP preferred
- Prior experience with Microsoft Office Suite preferred
- Prior experience with clinical record review preferred
- Prior experience with CDI software preferred
- Minimum Work Experience: 1-3 years of experience working in chart review procedures, typically acquired by work experience of a clinical documentation improvement specialist, utilization review nurse, or inpatient coder.
- Required Skills: Requires critical thinking skills, decisive judgment, and the ability to work with minimal supervision. Must be able to work in a stressful environment and take appropriate action.
Benefits
- 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.
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard skills
patient assessmentsnursing interventionsclinical documentationQI assessmentscoding expertisemetrics reportschart review proceduresclinical documentation improvementutilization reviewinpatient coding
Soft skills
critical thinkingdecisive judgmentability to work with minimal supervisionstress managementcommunicationorganizational skillspresentation skillscollaborationproblem-solvingattention to detail
Certifications
RN licenseRHIARHITCCDSCDIP