Lead Clinical Documentation Specialist

Your experience matters 

Raleigh General Hospital is part of Lifepoint Health, 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 a Lead Clinical Documentation Specialist joining our team, you're embracing a vital mission 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 

At Raleigh General Hospital people are our passion and purpose. Come work where you are appreciated for who you are not just what you can do. We offer a wide range of surgical services as well as specialty programs including Cardiac CTA, Digital Mammography, and Trauma Services.

How you'll contribute 

A Lead Clinical Documentation Specialist who excels in this role:

• Leads initiatives to improve the overall quality, completeness, and accuracy of inpatient clinical documentation, ensuring the medical record accurately reflects clinical treatment, severity of illness, risk of mortality, and diagnoses.
• Conducts and oversees comprehensive reviews of inpatient medical records, identifies documentation opportunities, and ensures timely follow-up and resolution of provider queries.
• Utilizes advanced clinical and coding expertise to develop and guide compliant physician query practices in alignment with accepted coding guidelines and organizational policy.
• Collaborates with physicians, case management, coding, and hospital leadership to promote documentation practices that positively impact quality metrics, reimbursement, physician profiling, and organizational performance outcomes.
• Analyzes, tracks, and trends CDI data and performance metrics, identifies improvement opportunities, and leads process improvement initiatives across the organization.
• Serves as a subject matter expert and primary resource for CDI education, providing training, mentorship, and ongoing guidance to CDI staff, physicians, and interdisciplinary team members.
• Brings prior CDI experience and demonstrated leadership capability, supporting program development, auditing, performance oversight, and strategic CDI initiatives.

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 medical, dental and vision coverage for full-time and part-time employees.
• Financial Protection & PTO: Life, accident, critical illness, hospital indemnity insurance, short- and long-term disability, paid family leave and paid time off.
• Financial & Career Growth: Higher education and certification tuition assistance, loan assistance and 401(k) retirement package and company match.
• Employee Well-being: Mental, physical, and financial wellness programs (free gym memberships, virtual care appointments, mental health services and discount programs).
• Professional Development: Ongoing learning and career advancement opportunities.

What we're looking for

• Current state RN or LPN/LVN license with BCLS certification required.
• Minimum of 3 years of clinical documentation improvement experience, preferably in a lead or senior role; Bachelor's degree preferred.
• Prior leadership experience demonstrating the ability to mentor, audit, and oversee CDI staff and initiatives.
• Advanced knowledge of ICD-10 coding guidelines, DRG/APR-DRG methodologies, and their impact on severity of illness, risk of mortality, and quality metrics.
• Familiarity with CMS regulations, value-based purchasing programs, and hospital quality reporting requirements.
• Proven ability to lead physician engagement, conduct compliant provider queries, and educate interdisciplinary teams effectively.
• Strong analytical skills with experience tracking, trending, and driving process improvements using CDI performance data and metrics.
• Proficiency with electronic health records (EHR) and CDI software platforms.
• Preferred certifications include RHIT, RHIA, CCDS, or CDIP.
• Exceptional critical thinking, decisive judgment, and the ability to work independently in fast-paced, high-pressure environments while maintaining professionalism and accountability.

More about Raleigh General Hospital

 

Raleigh General Hospital cares for nearly 13,000 patients each year and treats more than 50,000 patients in its emergency room. We are accredited by the Joint Commission, the nationally recognized accrediting agency for healthcare facilities. Raleigh General Hospital also offers instructional programs for nursing students as well as numerous allied health student extern programs.

EEOC Statement

"Raleigh General Hospital is an Equal Opportunity Employer. Raleigh General Hospital is committed to Equal Employment Opportunity for all applicants and employees and complies with all applicable laws prohibiting discrimination and harassment in employment."

Lifepoint Health is a leader in community-based care and driven by a mission of Making Communities Healthier. Our diversified healthcare delivery network spans 29 states and includes 63 community hospital campuses, 32 rehabilitation and behavioral health hospitals, and more than 170 additional sites of care across the healthcare continuum, such as acute rehabilitation units, outpatient centers and post-acute care facilities. We believe that success is achieved through talented people. We want to create places where employees want to work, with opportunities to pursue meaningful and satisfying careers that truly make a difference in communities across the country.