Market Specialist, Clinical Documentation

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. Centerpoint Health-Winchester is a 79 bed community hospital featuring updated technology including new and expanded services such as Diagnostic Services, larger capacity Emergency Services, home-like Labor and Delivery Suites, and a skilled nursing facility. The campus also includes a 45,000 square foot Medical Plaza housing the Clark Clinic, Diagnostic Center for Women, Center for Rehabilitation, Specialty Clinic and Anticoagulation Clinic.

Where We Are:

Winchester offers a truly original experience to all with so much to do and see. Just a short drive from Lexington, the "Horse Capital of the World," and the Red River Gorge, you can experience all the beauty and excitement nature has to offer. 

Why Join Us

We believe that investing in our employees is the first step to providing excellent patient care.

Benefits Include:

• Comprehensive Health Coverage: Medical, dental, and vision plans (starting at low cost options)
• Financial Protection: Life, accident, disability, and critical illness coverage
• Paid Time Off & Leave: Generous PTO and paid family leave
• Retirement Planning: 401(k) with company match
• Tuition Assistance: Education support for career advancement
• Wellness Programs: Free gym memberships, mental health services, and virtual care
• Employee Assistance Program: Support for mental, physical, and financial well-being
• Additional Perks: Discount programs, free parking, and more

Job Summary

The Market Clinical Documentation Specialist's primary responsibility is to facilitate improvement in the overall quality, completeness, and accuracy of clinical documentation. Through concurrent interaction with physicians, nurses, case managers, coders, and other health care team members, the Clinical Documentation Integrity Specialist (CDIS) strives to ensure comprehensive medical record documentation that reflects clinical treatment, decision-making, and diagnoses for all Medicare inpatients. This role serves as a resource to members of the health care team on documentation guidelines and provides guidance, support, education, and training related to improving clinical documentation. The position also actively participates in educating appropriate hospital and medical staff about ICD-10.

Key Responsibilities

- Abstract clinical data from the medical record to accurately code and sequence diagnoses and procedures, ensuring documentation supports maximum reimbursement.

- Concurrently abstract information from the medical record in accordance with the conventions and rules associated with the International Coding Classification of Diseases and Operations.

- Abstract information from the medical record in accordance with guidelines defined by Meditech, the medical center, HCFA, and state and federal databases.

- Conduct daily reviews of inpatient medical records to identify missing, vague, and/or incomplete diagnoses and procedures.

- Perform timely follow-up reviews to ensure issues discussed and queries left in the medical record have been answered by the provider.

- Utilize coding and clinical expertise to identify opportunities and ensure the accuracy and completeness of documentation for physician and hospital outcome reporting.

- Query physicians on specificity of diagnoses and procedures based on accepted coding guidelines, clinical expertise, and organizational policy.

- Track and trend improvement opportunities through the query process using approved metrics and reporting.

- Conduct education sessions with physicians and other health care team members on documentation requirements.

- Participate in CDI onboarding education for new admitting physicians.

- Review clinical issues and query response concerns with physician advisors.

- Participate in data collection and reporting to support quality improvement and clinical documentation initiatives.

- Stay current with CMS IPPS requirements, AHA Coding Clinic guidance, and Official Guidelines for Coding and Reporting related to ICD-10.

- Collaborate with nursing, case management, quality, risk management, credentialing, and medical staff leadership to support effective documentation and improvement plans.

- Prepare and present educational programs related to clinical documentation issues.

- Perform other duties as assigned by the Director.

Minimum Qualifications

- Licensure as a Registered Nurse (RN), Licensed Practical Nurse (LPN), RHIA, RHIT, or a combination thereof preferred.

- CCDS or CDIP certification preferred.

- Coders must have CCS or CIC credentials.

Required Skills & Competencies

- Strong critical thinking skills and decisive judgment.

- Ability to work with minimal supervision.

- Ability to work effectively in a stressful environment and take appropriate action.

- Strong knowledge of clinical documentation improvement, coding guidelines, and ICD-10 reporting requirements.

- Ability to establish cooperative working relationships with physicians, clinical staff, and interdisciplinary teams.

- Effective verbal and written communication skills for education, reporting, and provider query follow-up.

- Understanding of legal and ethical issues related to confidentiality and coding activities.

- Ability to analyze data, identify trends, and support operational and quality improvement initiatives.

EEOC Statement:

Centerpoint Health-Winchester 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.

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.