CDI Specialist RN

Lexington Medical Center; West Columbia (SC); On-site; USD 65,000 - 90,000; Full time

Benefits offered by this job

Day ONE medical, dental and life保险

FSAs for health care and dependent

403(b) match from day one

Employer paid life insurance

Student loan forgiveness

Job summary

Lexington Health seeks a Clinical Documentation Improvement Specialist to perform concurrent reviews, query physicians, and ensure accurate documentation supporting DRG assignment and patient severity.

Role requires RN licensure in South Carolina, 3 years acute care experience, and CCDS/CDIP certification or eligibility within 2 years. Join a network focused on improving care and documentation quality.

Qualifications

• Associate's Degree in Nursing (minimum)
• 3 years of clinical experience in an acute care setting
• RN license to practice in SC; CCDS/CDIP certification or eligible within 2 years

Responsibilities

• Collaborates with providers to assign working DRGs and identify diagnoses/procedures
• Verifies documentation accuracy and completeness for medical necessity and DRG outcomes
• Conducts thorough medical record review for initial and extended-stay cases to identify MCCs/CCs, PSI, HAC, and mortality risk

Skills

Clinical documentation

Communication

Team collaboration

Education

Associate’s Degree in Nursing

Job description

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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-bedteachinghospital in West Columbia, South Carolina. It was selected by Modern Healthcare as one of the Best Places to Work in Healthcareand was first in the state to achieve Magnet with Distinctionstatus for excellence in nursing care. Consistently ranked as bestin the Columbia Metroarea by U.S. News & World Report, Lexington Healthdelivers more than 4,000babies each year, performs more than 34,000surgeries annually and isthe 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.