CDI Specialist RN

Lexingtononcology; Columbia (SC); On-site; USD 85,000 - 110,000; Full time

Benefits offered by this job

Day ONE benefits

FSAs

403(b) match

Life insurance

Supplemental life

Adoption assistance

Disability coverage

Student loan forgiveness

Job summary

Lexington Health in West Columbia, SC, seeks a skilled Clinical Documentation Improvement Specialist to conduct thorough concurrent reviews of medical records, capturing principal and secondary diagnoses and procedures to support accurate DRG assignment.

Collaborate with physicians, nurses, and case managers to clarify documentation, ensure compliance, and identify MCCs/CCs, PSI, and mortality indicators. Requires RN license in SC and CCDS/CDIP certification or eligibility within 2 years.

Qualifications

• RN license to practice in South Carolina required.
• Associate’s Degree in Nursing required.
• Certification from ACDIS (CCDS) or AHMIA (CDIP) or eligible within 2 years.
• Experience in acute care and concurrent medical record reviews preferred.

Responsibilities

• Collaborate with physicians, nurses, and case managers to identify diagnosis options and DRGs.
• Clarify documentation needs using effective written/verbal communication.
• Review records to identify MCCs/CCs, PSI, HAC, and patient severity of illness.
• Maintain confidentiality of patient information and documentation.

Skills

Clinical documentation

ACDIS knowledge

Communication skills

Confidentiality

Education

Associate’s Degree in Nursing

Tools

ICD-10-CM

ICD-10-PCS

AHA Coding Clinics

CMS Guidelines

Job description

Lexington Health is a comprehensive network of care that includes six community medical and urgent care centers, nearly 80 physician practices, more than 9,000 health care professionals and Lexington Medical Center, a 607‑bed teaching hospital in West Columbia, South Carolina. It was selected by Modern Healthcare as one of the Best Places to Work in Healthcare and was first in the state to achieve Magnet with Distinction status for excellence in nursing care. Consistently ranked as best in the Columbia Metro area by U.S. News & World Report, Lexington Health delivers more than 4,000 babies each year, performs more than 34,000 surgeries annually and is the region's third largest employer.

Lexington Health also includes an accredited Cancer Center of Excellence, the state’s first HeartCARE Center, the largest skilled nursing facility in the Carolinas, and an Alzheimer’s care center. Its postgraduate medical education programs include family medicine and transitional year residencies, as well as an informatics fellowship.

Job Summary

Provides thorough concurrent review of medical record clinical documentation to capture documented and potential principal diagnosis, secondary diagnoses and procedures affecting DRG assignment and profiling outcomes. Queries the medical staff and other caregivers as necessary via written/verbal communication to obtain accurate and complete physician documentation that supports DRG assignment and the severity of patient illness and risk of mortality.

Minimum Qualifications

• Minimum Education: Associate’s Degree in Nursing
• Minimum Years of Experience: 3 Years of Clinical Experience in an Acute Care Setting
• Substitutable Education & Experience (Optional): None
• Required Certifications/Licensure: Current RN License to Practice in the State of South Carolina; Currently has certification from ACDIS (Certified Clinical Documentation Specialist - CCDS) or AHMIA (Certified Documentation Improvement Practitioner - CDIP) or eligible certification must be obtained from one of these entities within 2 years of entry into the role.
• Required Training: None

Essential Functions

• Collaborates with physician, physician extender, nurse, case manager/utilization reviewer and Medical Records coder to identify principal diagnosis options, secondary diagnoses and procedures, to assign working DRGs for identified populations.
• Identifies need to clarify documentation in records. Utilizes strong communication skills with physician, physician extender, case manager, utilization reviewer, nurse or other healthcare professionals, utilizing appropriate tools to capture needed documentation.
• Able to conduct thorough medical record review on initial and extended‑stay concurrent reviews on all selected inpatient admission and documents findings to identify MCCs/CCs, PSI, HAC, mortality second‑level review, and patient length of stay that supports patient’s severity of illness and risk of mortality denoting all key information utilized in the tracking process.
• Maintains complete confidentiality of patient information, in addition to hospital and individual physician practice pattern data.
• Assure all documentation is accurate, complete, and compliant, supporting acute or chronic conditions and medical necessity.

Duties & Responsibilities

• Develop and sustain positive working relationships with providers, advanced practice providers, administrators, peers, and other collaborating departments to promote the success of the CDI program.
• Able to effectively prioritize tasks with workflow.
• Stay up to date with industry standards by participating in internal and external continuing education related to ACDIS, ICD‑10‑CM coding, ICD‑10‑PCS coding, AHA Coding Clinics, and CMS Official Coding Guidelines.
• Able to utilize software, programs, and other technology tools to prioritize and maintain workflow.
• Performs all other duties as assigned.

We are committed to offering quality, cost‑effective benefits choices for our employees and their families:

• Day ONE medical, dental and life insurance benefits
• Health care and dependent care flexible spending accounts (FSAs)
• Employees are eligible for enrollment into the 403(b) match plan day one. LHI matches dollar for dollar up to 6%.
• Employer paid life insurance – equal to 1x salary
• Employee may elect supplemental life insurance with low cost premiums up to 3x salary
• Adoption assistance
• LHI provides its full‑time employees employer paid short‑term disability and long‑term disability coverage after 90 days of eligible employment
• Student loan forgiveness

Equal Opportunity Employer
It is the policy of Lexington Health to provide equal opportunity of employment for all individuals, and to remain compliant with applicable state and federal laws and regulations. Lexington Health strives to provide a discrimination‑free environment, and to recruit, select, on‑board, and employ all employees without regard to race, color, religion, sex, age, disability, national origin, veteran status, or pregnancy, childbirth, or related medical conditions, including but not limited to lactation. Lexington Health endeavors to upgrade and promote employees from within the hospital where possible and consistent with the employee’s desires and abilities and the hospital’s needs.