Clinical Documentation Pro: Elevate Care & Coding

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

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.