CDI Specialist RN

Lexington Medical Center • SC

121d

About The Position

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.

Requirements

• Minimum Education: Associate’s Degree in Nursing
• Minimum Years of Experience: 3 Years of Clinical Experience in an Acute Care Setting
• 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.

Responsibilities

• 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.
• 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.

Benefits

• 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
• Tuition reimbursement
• Student loan forgiveness

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree
• Number of Employees: 5,001-10,000 employees