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Your next career move matters. We invite you to explore open positions at Clark Regional Medical Center, which is part of Lifepoint Health, a diversified healthcare delivery network committed to making communities healthier® and creating places where employees want to work. Whether you’re an experienced professional or just beginning your career, you’ll find opportunities to use your skills and expertise.

Clinical Documentation Information Specialist / Coder

Winchester, Kentucky

Req ID 302334 Post Date May. 05, 2025 CategoryRevenue Cycle Management FacilityClark Regional Medical Center
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Clark Regional Medical Center

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. Clark Regional Medical Center 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 Choose Us:

  • Health (Medical, Dental, Vision) and 401K Benefits for full-time employees
  • Competitive Paid Time Off
  • Employee Assistance Program – mental, physical, and financial wellness assistance
  • Tuition Reimbursement/Assistance for qualified applicants
  • Membership discounts with local gyms and community businesses
  • Free Parking
  • And much more…

Preferred Qualifications-               

  • Certifications: CCDS or CDIP, Preferred
  • Coders must have CCS or CIC, Required
  • RHIA or RHIT, Preferred
  • Minimum 2 years In-Patient Acute Care Coding experience, Highly Preferred

Other Qualifications Considered with Coding experience - 

  • Licenses: Licensed Registered Nurse (RN) 
  • Licensed Practical Nurse (LPN), or combination thereof 

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), will strive to ensure comprehensive medical record documentation that reflects the clinical treatment, decisions, and diagnosis for all Medicare inpatients. 
  • Serving as a resource to all members of the health care team on documentation guidelines, this position will provide guidance and support, as well as assisting with education and training related to improving clinical documentation. 
  • This position will actively participate in educating appropriate hospital and medical staff about ICD-10. Additionally, the CDIS will: 
  • 1. Abstract clinical data from the medical record to accurately code and sequence diagnoses and procedures ensuring accuracy of medical record documentation to support maximum reimbursement 
  • 2. Concurrently abstract information from the medical record in accordance to the conventions and rules associated with the International Coding Classification of Diseases and Operations 
  • 3. Abstract information from the medical record in accordance with abstracting guidelines as defined by Meditech, the medical center, HCFA, state and federal databases. 
  • 4. Other duties as assigned by the Director Job Requirements 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.    
  • Hybrid work schedule will be considered.
  • Must maintain credentials as indicated below, through continuing education

Essential Job Functions:

  • Essential Functions Within this scope, the CDIS’s essential functions will include but are not limited to: • 
  • Conducts daily reviews of inpatient medical records either in the nursing unit and/or on the computer to identify missing, vague, and/or incomplete diagnoses and procedures 
  • Conducts timely follow-up reviews of clinical documentation to ensure that issues discussed and queries left in the medical record have been answered by the provider 
  • Utilizes coding and clinical expertise to identify opportunities and ensure the accuracy and completeness of clinical documentation for measuring and reporting physician and hospital outcomes       
  • Queries physicians on specificity of procedures performed and diagnosis based on accepted coding guidelines, clinical expertise and LifePoint Hospitals policy 
  • Tracks and trends specific opportunities for improvement through the query process utilizing approved metrics reporting 
  • Conducts educational sessions with physicians and other health care team members on documentation requirements 
  • Conducts CDI on-boarding education of all new admitting physicians as part of the hospitals orientation program  
  • Reviews clinical issues and identified query response concerns with physician advisors 
  • Participates in data collection to document findings and outcomes to drive quality improvement and improved clinical documentation 
  • Stays current with requirements of CMS Inpatient Prospective Payment Systems (IPPS), AHA Coding Clinic and Official Guidelines for Coding and Reporting related to ICD-10  
  • Participates in department and facility Quality and Performance initiatives 
  • Works closely with nursing, case management, quality, risk management, and medical staff credentialing to provide data related to key clinical indicators and operational metrics  
  • Works in conjunction with the Director of Quality, Medical Staff Credentialing and medical staff leadership to assure effective monitoring and successful completion of identified plans for improvement  
  • Prepares and presents educational programs to all internal constituents related to clinical documentation issues and coordinates same with clinical staff, physicians, compliance and coding staff  
  • Makes regular reports of progress toward goals associated with clinical documentation improvement opportunities and operational improvement plans  
  • Establishes cooperative working relationship with diverse groups and individuals, medical staff and other health care disciplines and interact with all levels of employees 
  • Develops and maintains a professional working relationship with medical staff, clinical staff, medical records and business office staff 
  • Maintains a knowledge base of the characteristics of disease, illness, disabling conditions that directly impact the patient’s state of physical or mental health  
  • Collaborates, coordinates and consults with members of the healthcare team to facilitate appropriate documentation in the medical record for concurrent chart abstraction and coding  
  • Understands the legal and ethical issues pertaining to confidentially as well as liability issues for coding activities • 
  • Attends meetings as required and participates on committees and teams as directed 

Functional Demands Populations Served Does not treat or care for patients. Protected Health Information Type of Protected Information Accessed: Demographic Clinical Insurance Financial Complete Medical Record Bloodborne Pathogens Exposure While performing this job, occupational exposure is present for all employees Physical Requirements - Physical Dexterity and Effort: Rarely       

EEOC Statement:

Clark Regional Medical Center 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.

We employ and provide care to people from all walks of life. We are committed to promoting healing, providing hope, preserving dignity and producing value with an inclusive workforce in which diversity is leveraged, respected, and reflective of the patients, family members, customers and team members we serve.

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