Clinical Documentation Improvement Specialist - Full Time

Lake Charles Memorial Hospital; Lake Charles (LA); On-site; USD 60,000 - 80,000; Full time

Job summary

Lake Charles Memorial Hospital is seeking a Clinical Documentation Improvement Specialist for a full-time position in Lake Charles, LA. The role involves improving the quality and accuracy of medical records through interaction with medical staff. Candidates must have a relevant clinical degree and at least one year of coding experience in acute care. Additional certifications in clinical documentation are preferred. The position requires effective communication skills and the ability to adapt to various physical demands of the role.

Qualifications

• One year clinical documentation or coding experience in acute care setting.
• Strong communication skills with physicians required.
• Clinical Documentation Improvement Practitioner (CDIP) or Certified Clinical Documentation Specialist (CCDS) is a plus.

Responsibilities

• Review inpatient admissions to improve documentation quality.
• Initiate physician interaction to clarify documentation.
• Maintain communication with the patient care team and coding staff.

Skills

Interpersonal skills

ICD-9 or ICD-10 coding knowledge

Computer skills

Education

Clinical allied health degree

Certification/Licensure: MD, DO, PA, RN/BSN, RHIA, or RHIT

Job description

Clinical Documentation Improvement Specialist - Full Time

Department: Clinical Document

Location: Lake Charles, LA

DESCRIPTION OF POSITION:

• The Clinical Documentation Improvement Specialist facilitates the improvement of the overall quality, completeness and accuracy of medical record documentation. To obtain and promote appropriate clinical documentation through extensive interaction with physicians and other members of the patient care team and coding staff. To ensure Clinical Documentation reflects the level of service, severity of illness and is complete and accurate.

SUPERVISION: Reports directly to the Director of CDI

RESPONSIBILITIES AND DUTIES:

• Concurrently reviews inpatient admissions to identify opportunities to improve the quality of documentation.
• Complies with all relevant policies, procedures, guidelines and other regulatory, compliance and accreditation standards.
• Initiates physician interaction to clarify ambiguous or conflicting documentation and assure any clarification is noted in the patient record according to policy.
• Maintains positive and open communication with physicians, members of the patient care team, and coding staff.
• Assumes responsibility for professional development by participating in workshops, conferences and/or in-services.
• Relates the importance of complete documentation on coding quality, DRG assignment, physician profiling, case mix index and expected mortality rates.
• Keeps current with changes in coding guidelines, compliance, reimbursement, and other relevant regulatory updates.
• Understands the general flow of health information from medical record documentation and discharge, coding, billing and finally data reporting.

The above statements are only meant to be a representative summary of the major duties and responsibilities performed by incumbents of this job. The incumbents may be requested to perform job-related tasks other than those stated in this description.

Certification, Registration, or Licensure Required

• Must have one of the certifications/licensures: Doctor of Medicine (MD), Doctor of Osteopathy (DO), Foreign Medical Graduate (FMG), Physician Assistant (PA), Registered Nurse/BSN, RHIA, RHIT, or related clinical allied health degree
• Clinical Documentation Improvement Practitioner (CDIP), Certified Clinical Documentation Specialist (CCDS), Certified Coding Specialist (CCS), or equivalent is a plus
• Minimum 1-year clinical documentation, coding experience in acute care setting.
• Knowledge of ICD-9 or ICD-10 coding, as well as strong computer skills preferred, however content training in coding will be provided.
• Work requires superior interpersonal skills and demonstrated ability to communicate effectively with physicians is essential.

Physical Demands/Work Environment

• Work requires a variety of physical activities, including moving about within and outside of all hospital properties for long periods of time.
• Must be able to respond quickly and effectively to emergency and non-emergent situations.
• May be required to assist in controlling disorderly conduct or combative patients.
• Must be able to exchange accurate information with patient, family, peers and medical personnel.
• Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions