CDI Specialist: Elevate Medical Documentation & Coding

LCMC Health; United States; On-site; USD 70,000 - 90,000; Full time

Job summary

LCMC Health seeks a CDI Specialist to facilitate complete and accurate medical record documentation at the point of service, communicating with physicians, coders, and the health care team to reflect clinical decisions for inpatients and outpatients. The role focuses on improving quality, accuracy, and completeness of documentation for proper reimbursement.

The CDI Specialist will conduct concurrent and retrospective reviews, educate staff, and collaborate with multidisciplinary teams across

Qualifications

• Bachelor’s Degree in Nursing or HIM is required.
• 2 years of experience in Clinical/Nursing & Case Management or Coding with an Associate’s Degree.
• Must have one of the following certifications/licensures: RN/BSN, LPN (LA), CDS, RHIA, RHIT or AHIMA/AAPC.

Responsibilities

• Conducts reviews and analyses of health records to identify relevant diagnoses.
• Collaborates with physicians, nurses, coders, and staff to improve documentation quality.
• Provides ongoing education to the patient care team on documentation improvements.
• Oversees concurrent and retrospective reviews to improve accuracy and completeness of provider documentation.
• Ensures billing accuracy and reimbursement through proper documentation.

Skills

ICD-10-CM/PCS knowledge

Coding accuracy

Analytical abilities

Communication skills

Collaboration

Education and training

Education

Bachelor’s Degree in Nursing or HIM

Associate’s Degree in Clinical/Nursing or Coding

Certifications/licensures: RN/BSN, LPN (LA), CDS, RHIA, RHIT, or AHIMA/AAPC

Tools

Electronic Health Record (EHR) systems

CPT/HCPCS, ICD-10-CM/PCS knowledge

MS-DRG/APR-DRG guidelines

HIPAA privacy & security regulations

Job description

LCMC Health seeks a CDI Specialist to facilitate complete and accurate medical record documentation at the point of service, communicating with physicians, coders, and the health care team to reflect clinical decisions for inpatients and outpatients. The role focuses on improving quality, accuracy, and completeness of documentation for proper reimbursement.

The CDI Specialist will conduct concurrent and retrospective reviews, educate staff, and collaborate with multidisciplinary teams across