Clinical Documentation Specialist

This is a fully remote position, open to applicants in United States.

📋 Description

• Perform daily concurrent reviews of medical records to detect any missing, ambiguous, or incomplete diagnoses and procedures.

• Execute timely follow-up reviews of clinical documentation to verify that the issues discussed and the queries issued have been addressed by providers.

• Engage with physicians to clarify the specificity of procedures conducted and diagnoses based on established coding guidelines, clinical knowledge, and Lifepoint Health query policies.

• Participate in departmental and facility Quality and Performance initiatives.

• Keep education records updated and fulfill the minimum corporate CEU requirements.

• Maintain a tidy workstation and adhere to safety regulations, the Code of Conduct, ethical standards, customer service expectations, hospital training, and departmental staff meetings.

• Operate with critical thinking, decisive judgment, and minimal oversight.

• Thrive in a high-pressure environment and respond appropriately.

• Carry out other related duties as assigned.

⛳️ Requirements

• Bachelor’s Degree in Nursing.

• A minimum of three years of clinical experience required in an emergency room and/or ICU setting.

• Active RN license.

• Must have authorization to work in the United States without employer sponsorship.

• Strong critical thinking skills and decisive judgment.

• Capability to work with minimal supervision.

• Ability to perform effectively in a stressful environment and take appropriate actions.

• Proficiency in adhering to accepted coding guidelines and Lifepoint Health query policies.

🏝️ Benefits

• Flexible shifts: employees provide their manager with their available days and start/end times.

• PRN opportunities to work 20–30 hours per week.

• Corporate continuing education unit (CEU) requirements.

• Hospital training.

• Departmental staff meetings.