CDI Specialist: Elevate Clinical Documentation

Lake Charles Memorial Health System; Lake Charles (LA); On-site; USD 70,000 - 90,000; Full time

Job summary

Lake Charles Memorial Health System is seeking a Clinical Documentation Improvement Specialist to enhance the quality, completeness and accuracy of medical record documentation. You will interact with physicians and care teams to promote proper documentation reflecting service level and severity of illness.

The role requires reviewing inpatient admissions, clarifying ambiguous notes, and ensuring documentation supports DRG assignment and data reporting.

Qualifications

• Must have one of the listed certifications/licensures (MD/DO/FMG/PA/RN-BSN/RHIA/RHIT or related clinical degree).
• Minimum 1 year of clinical documentation/coding experience in an acute care setting.
• Knowledge of ICD-9 or ICD-10 coding; strong computer skills; content training provided.
• Strong interpersonal skills and ability to communicate effectively with physicians are essential.

Responsibilities

• Review inpatient admissions to identify opportunities to improve documentation quality.
• Comply with all relevant policies, procedures, guidelines and regulatory standards.
• Initiate physician interaction to clarify ambiguous documentation and note clarifications in patient records.
• Maintain positive communication with physicians, care team and coding staff.
• Participate in professional development through workshops and in-services.
• Highlight the importance of complete documentation on coding quality, DRG assignment, case mix index and mortality rates.
• Stay current with changes in coding guidelines, compliance and regulatory updates.
• Understand health information flow from documentation through discharge, coding, billing and data reporting.

Skills

Interpersonal skills

Physician communication

Education

Medical degree (MD/DO) or nursing degree (RN/BSN)

RHIA/RHIT/CDDS/CDIP

Tools

ICD-9/ICD-10 knowledge

Job description

Lake Charles Memorial Health System is seeking a Clinical Documentation Improvement Specialist to enhance the quality, completeness and accuracy of medical record documentation. You will interact with physicians and care teams to promote proper documentation reflecting service level and severity of illness.

The role requires reviewing inpatient admissions, clarifying ambiguous notes, and ensuring documentation supports DRG assignment and data reporting.