Clinical Documentation Specialist

    September 20, 2021
    Lexington, Kentucky
    Job Type


    Our client, a 70+ bed hospital in KY, about 30 mins from Lexington, has a need for an experienced Clinical Documentation Specialist to join their team.  This position requires you to be ON-SITE!

    10 K Sign on

    • Conducts daily concurrent reviews of 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 issued queries have been answered by providers.
    • Queries physicians on specificity of procedures performed and diagnoses based on accepted coding guidelines, clinical expertise and LifePoint Health query policy.
    • Participates in department and facility Quality and Performance initiatives.
    • Maintains education record with meets minimum corporate CEU requirements.
    • Maintains clean work station, follows all safety regulations, Code of Conduct and ethics, customer service, and attends hospital training and departmental staff meetings.

    Job Requirements

    Minimum Education: Associate’s Degree Nursing (ADN): Required and validated by the presence of a current KY RN license.  Bachelor’s Degree Nursing (BSN): Preferred

    Licenses: Registered Nurse, KY

    Certifications: One of the following is Preferred: Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Coding Specialist - Physician-base (CCS-P), Certified Coding Specialist (CCS)

    Minimal completion of Level One on the Clinical Ladder Program annually for Full-time nurses. If not completed, employee forfeits the annual evaluation pay increase and possible termination.

    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.

    Must have thorough understanding of ICD-10 Official Coding Guidelines for Coding and Reporting and AHA Coding Clinic; HCPCS/CPT coding systems and CPT Assistant and Coding Clinic for HCPCS guidelines; Medicare Outpatient Prospective Payment System (OPPS), and Ambulatory Payment Classification (APC).

    Minimum Work Experience: Three years of clinical work experience Required

    In the heart of the Bluegrass is the charm and beauty of the entire state distilled into one community: Ours, centrally located in the golden triangle of Cincinnati, Louisville and Lexington. An image that describes the town best is a sleek thoroughbred racehorse grazing a lush Bluegrass paddock. Thoroughbreds are just one of the many breathtaking attributes in and around the town. With its American flags, hanging flower baskets and picturesque Victorian-era downtown buildings, this historic town exemplifies small town America. Discover our southern hospitality, friendly faces and social atmosphere.

    Salary range is $49,900—72,800 DOE.  $10,000 sign on bonus.


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