Clinical Documentation Specialist
Lenoir Memorial Hospital - Kinston, NC

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BS -Health Info Mgmt or Associates Degree Health Info Techno
  • RHIA or RHIT required
  • 2-4yr exp in ICD-9CM & CPT coding in acute care setting requ
  • Responsible for the overall improvement of quality completeness of medical record documentation through auditing and evaluation of documentation to adequtely reflect care provided and resources used. Responsibilities include facilitation of appropriate physician documentation of care to accurately reflect patient severity of illness and risk of mortality. Solicits clarification from physicians and clinical staff in areas where further specificity is needed and consults with physicians when conflicting information appears in the medical record.

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