Clinical Documentation Specialist

**Your experience matters** Haywood Regional Medical Center is part of [Lifepoint Health](https://lifepointhealth.net/locations), 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 the **Clinical Documentation Specialis**t, you will review patient medical records to ensure documentation is accurate, complete, and compliant, collaborating with providers to clarify diagnoses and procedures in accordance with coding guidelines and organizational policies. You will also support quality improvement initiatives, maintain required continuing education, and uphold compliance, safety, and professional standards to promote accurate clinical documentation and optimal patient care. In this role, you'll join a team 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. **More about our team** **How you'll contribute** Join our team at Haywood Regional Medical Center, where a long-standing tradition of excellence meets a commitment to exceptional patient care. As a leading healthcare provider in Western North Carolina, we offer a comprehensive range of services, including Orthopedics, Spine Services, Cardiology, Emergency Medicine, General Surgery, Women's Care, and Behavioral Health, supported by 11 multi-specialty physician clinics. Our growing health system also features a modern Outpatient Care Center, Health & Fitness Center, and two urgent care locations, creating a collaborative environment dedicated to improving the health and well-being of the communities we serve. **How you'll contribute** A Clinical Documentation Specialist who excels in this role will: - 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 to ensure medical records accurately reflect patient diagnoses, treatments, and clinical decisions. - 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. **Schedule:** **Full-Time; Days** **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 medi…