CDI Specialist: Elevate Medical Record Quality

Lake Charles Memorial Health System; Lake Charles (LA); On-site; USD 65,000 - 85,000; Full time

Job summary

Lake Charles Memorial Health System is seeking a Clinical Documentation Improvement Specialist to enhance the accuracy, completeness and quality of medical record documentation. You will work closely with physicians and the care team to ensure documentation reflects severity of illness and level of service, influencing coding quality and outcomes.

The role requires collaboration with CDI staff and coding professionals, ongoing professional development, and vigilance about regulatory updates to

Qualifications

• Minimum 1-year clinical documentation, coding experience in acute care setting.
• Knowledge of ICD-9 or ICD-10 coding.
• Superior interpersonal skills and demonstrated ability to communicate effectively with physicians.
• Strong computer skills; content training in coding will be provided.

Responsibilities

• Concurrently reviews inpatient admissions to identify opportunities to improve documentation quality.
• Complies with all relevant policies, procedures, guidelines and standards.
• Initiates physician interaction to clarify ambiguous documentation and notes clarifications in the patient record.
• Maintains positive communication with physicians, care team, and coding staff.
• Engages in professional development through workshops and trainings.
• Explains the importance of complete documentation on coding quality, DRG assignment, and case mix index.
• Keeps current with coding guidelines, compliance and regulatory updates.
• Understands the health information flow from documentation to discharge, coding, billing and data reporting.

Skills

Interpersonal skills

Physician communication

ICD-9/ICD-10 coding

Education

Clinical allied health degree

Tools

Microsoft Office

Job description

Lake Charles Memorial Health System is seeking a Clinical Documentation Improvement Specialist to enhance the accuracy, completeness and quality of medical record documentation. You will work closely with physicians and the care team to ensure documentation reflects severity of illness and level of service, influencing coding quality and outcomes.

The role requires collaboration with CDI staff and coding professionals, ongoing professional development, and vigilance about regulatory updates to