Job Description

RN-Clinical Documentation Spec at Raleigh General Hospital summary:

The RN-Clinical Documentation Specialist at Raleigh General Hospital ensures the accuracy and quality of clinical documentation in medical records. They conduct concurrent reviews, educate physicians on documentation standards, and support workflow improvements to enhance patient care. This role requires critical thinking, nursing licensure, and experience in inpatient coding within a hospital setting.

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.

Keywords:

clinical documentation, registered nurse, medical records, documentation review, physician education, inpatient coding, healthcare quality, clinical data integrity, patient care, hospital nursing

Job Tags

Full time, Work experience placement, Local area, Outdoor,

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