The RN-Clinical Documentation Specialist at Raleigh General Hospital ensures clinical data integrity by reviewing medical records and educating physicians on proper documentation. This role involves concurrent medical record reviews to enhance documentation quality and compliance. The position supports emergency services and requires a registered nurse license with skills in critical thinking and medical coding.
Description:
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€¦
JOB SUMMARY
Provide clinical data integrity to the facility.
Serve as resource for facility regarding documentation in the medical record.
Performs concurrent reviews of the medical record to improve documentation and educates physicians regarding documentation requirements as needed.
Reports to: Director of Emergency Services
ESSENTIAL FUNCTIONS
Evaluates the Quality of Clinical Documentation.
Provides training and education to the physicians.
Provides Work Flow Direction.
Responsible for Queries.
Qualifications:
JOB REQUIREMENTS
Minimum Education
Graduate of a Program in Discipline - Required
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
Required Licenses
[West Virginia, United States] Other
Current registered nurse licensure.
Minimum Work Experience
One (1) year of Inpatient Coding experience 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.
clinical documentation, medical record review, registered nurse, documentation integrity, physician education, emergency services, inpatient coding, patient care, healthcare compliance, critical thinking
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