Clinical Documentation Improvement Specialist - Full Time

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

Job summary

Lake Charles Memorial Health System seeks a Clinical Documentation Improvement (CDI) Specialist to enhance the quality, completeness and accuracy of medical record documentation. You will work with physicians and the patient care team to ensure documentation reflects severity of illness and services provided.

Key duties include reviewing inpatient admissions for documentation quality, clarifying ambiguous notes with clinicians, and staying current with coding guidelines and regulatory standards.

Qualifications

• Strong interpersonal skills and ability to communicate effectively with physicians and care teams.
• Knowledge of documentation standards and ability to promote accurate clinical documentation.

Responsibilities

• Concurrently reviews inpatient admissions to identify opportunities to improve documentation quality.
• Initiates physician interaction to clarify ambiguous documentation and ensures clarifications are recorded.
• Keeps current with coding guidelines, compliance standards, and regulatory updates.
• Understands the flow of health information from record documentation to data reporting.

Skills

Interpersonal skills

Communication with physicians

Education

RN/BSN or RHIA/RHIT endorsement

MD/DO/PA or related

Tools

ICD-9/ICD-10 coding

Job description

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

“Experience Memorial” is more than a slogan, it’s the care we provide our patients and it’s the commitment to our community and our team members. As a nationally certified Great Place to Work, at Lake Charles Memorial Health System you will have the opportunity to be a part of an organizational culture that supports not only exceptional patient care but also the well-being and professional growth of our employees. Join us and be a part of a team where your contributions are valued, your growth is nurtured, and your success is celebrated.

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