Raleigh General Hospital
Who We Are:
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.
Where We Are:
Beckley is an ideal place to live and boasts many scenic, cultural, and recreational opportunities. From restaurants and breweries to art galleries and unique attractions, Beckley is an outdoor playground with something for all tastes.
Why Choose Us:
Health (Medical, Dental, Vision) and 401K Benefits for Full time employees
Competitive Paid Time Off/Extended Illness Bank package for Full time employees
Employee Assistance Program – mental, physical, and financial wellness assistance
Educational assistance and tuition assistance for qualified applicants
Professional development opportunities and CE assistance
And much more
Position Summary:
Facilitates improvement in the overall quality, completeness, and accuracy of clinical documentation. Through concurrent interaction with physicians, case managers, coders and other health care team members, the Clinical Documentation Specialist, will strive to ensure comprehensive medical record documentation that reflects the clinical treatment, decisions, and diagnosis for all inpatients. Serving as a resource to all members of the health care team on documentation guidelines, this position will provide guidance and support, as well as assist with education and training related to improving clinical documentation. Provides concentrated daily oversight of the Clinical Documentation Improvement Team of registered nurses.
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.
Conducts educational sessions with physicians and other health care team members on documentation requirements.
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.
Assumes responsibilities for following compliance guidelines with federal, state, and local regulations within the department.
Reports to: Director of Health Information Management
Minimum Education
Bachelor’s degree – Preferred
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.
Certifications:
Basic Life Support (BLS) – to be obtained within 30 days
CCDS or CDIP preferred
Coders must have CS or CIC
Licenses:
Licensed Registered Nurse (RN), RHIA, RHIT, Licensed Practical Nurse (LPN), or combination thereof Preferred.
EEOC Statement:
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.
Equal opportunity and affirmative action employers and are looking for diversity in candidates for employment: Minority/Female/Disabled/Protected Veteran
