CDI Specialist RN

Lexington Health; Columbia (SC); On-site; USD 70,000 - 90,000; Full time

Benefits offered by this job

Day ONE benefits

403(b) matching plan

Tuition reimbursement

Student loan forgiveness

Short-term disability (after 90 days)

Job summary

Lexington Health in Columbia, SC, seeks a CDI Specialist to perform thorough concurrent review of medical record documentation, capture principal and secondary diagnoses and procedures, and query providers to ensure accurate DRG assignment and severity of illness.

The role emphasizes collaboration with clinicians, maintaining patient confidentiality, and staying current with ICD-10-CM/PCS coding guidelines; requires an Associate’s Degree in Nursing and an active SC RN license with required

Qualifications

• Associate’s Degree in Nursing required.
• 3 Years of Clinical Experience in an Acute Care Setting.
• RN License to Practice in South Carolina; CCDS or CDIP certification (or eligible within 2 years).

Responsibilities

• Collaborates with physicians, case managers, and other staff to identify principal/secondary diagnoses and procedures for DRG assignment.
• Clarifies documentation to ensure accuracy and completeness for coding and profiling.
• Conducts thorough medical record reviews to identify MCCs/CCs, PSI, HAC, and patient severity of illness.

Skills

Communication skills

Education

Associate’s Degree in Nursing

Job description

CDI

Full Time

Day Shift

730-4

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: 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.

Benefits

• 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
• Tuition reimbursement
• 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.

Nearest Major Market: Columbia

Nearest Secondary Market: South Carolina