Clinical Documentation Specialist, RN New

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 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 Clinical Documentation Specialist RN who excels in this role:

• Reviews inpatient medical records to identify missing, vague, or incomplete documentation and ensures timely resolution of provider queries.
• Ensures medical records accurately reflect clinical treatment, decisions, and diagnoses, supporting hospital quality reporting and outcomes.
• Uses clinical and coding expertise to query physicians for specificity of procedures and diagnoses, following hospital policy and accepted coding guidelines.
• Tracks and trends documentation opportunities using metrics to support process improvement initiatives.
• Provides guidance and education to physicians and clinical staff on best practices for clinical documentation and regulatory compliance.
• Collaborates with interdisciplinary teams to support quality initiatives, improve workflow, and enhance patient care outcomes.
  
   

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

• Valid West Virginia RN license required.
• BCLS certification required.
• Associate's degree in Nursing required.
•  Bachelor's degree in Nursing preferred.
• RHIA, RHIT, CCDS, or CDIP certification preferred.
• Minimum of 2-3 years of clinical documentation improvement experience preferred.
• Strong knowledge of ICD-10 coding guidelines, clinical documentation standards, and hospital regulatory requirements, including CMS and Joint Commission standards.
• Excellent communication and collaboration skills, with the ability to work effectively with physicians, case managers, coders, and other healthcare staff.
• Critical thinking, problem-solving, and organizational skills, with the ability to manage multiple tasks in a fast-paced hospital environment.

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.