Clinical Documentation Improvement Specialist - Full Time

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

Job summary

Lake Charles Memorial Health System is seeking a Clinical Documentation Improvement Specialist to enhance the accuracy, completeness and quality of medical record documentation. You will work closely with physicians and the care team to ensure documentation reflects severity of illness and level of service, influencing coding quality and outcomes.

The role requires collaboration with CDI staff and coding professionals, ongoing professional development, and vigilance about regulatory updates to

Qualifications

• Minimum 1-year clinical documentation, coding experience in acute care setting.
• Knowledge of ICD-9 or ICD-10 coding.
• Superior interpersonal skills and demonstrated ability to communicate effectively with physicians.
• Strong computer skills; content training in coding will be provided.

Responsibilities

• Concurrently reviews inpatient admissions to identify opportunities to improve documentation quality.
• Complies with all relevant policies, procedures, guidelines and standards.
• Initiates physician interaction to clarify ambiguous documentation and notes clarifications in the patient record.
• Maintains positive communication with physicians, care team, and coding staff.
• Engages in professional development through workshops and trainings.
• Explains the importance of complete documentation on coding quality, DRG assignment, and case mix index.
• Keeps current with coding guidelines, compliance and regulatory updates.
• Understands the health information flow from documentation to discharge, coding, billing and data reporting.

Skills

Interpersonal skills

Physician communication

ICD-9/ICD-10 coding

Education

Clinical allied health degree

Tools

Microsoft Office

Job description

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.

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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