Clinical Documentation Improvement Specialist II - Full Time

Lake Charles Memorial Hospital • Lake Charles, LA

1d • Onsite

About The Position

The Clinical Documentation Improvement Specialist II is an experienced, certified CDI with a broad clinical knowledge base and understanding of DRG documentation requirements. This role works under the supervision of the CDI Director and in collaboration with the CDI Educator. Responsibilities include secondary clinical chart reviews, resolution of DRG discrepancies, and improvement of capture of additional comorbid conditions to include HAC's and focused PSI diagnoses. The Clinical Documentation Improvement Specialist II will conduct concurrent secondary and retrospective medical record review for defined patient populations to identify opportunities to improve accuracy of documentation. This role collaborates with the Quality team, Case Managers, and the Coding department to assure documentation is clinically appropriate, accurately reflects the severity of illness for the patient, and is reflective of current CMS standards.

Requirements

• Advanced clinical expertise and extensive knowledge of complex disease processes with a broad clinical experience in an inpatient setting required.
• Minimum of 3 years’ experience as a Clinical Documentation Specialist required.
• Doctor of Medicine (MD), Doctor of Osteopathy (DO), Foreign Medical Graduate (FMG), Physician Assistant (PA), or Registered Nurse/BSN
• RHIA, RHIT, or related clinical allied health degree
• CCS, CCDS, or CDIP required

Responsibilities

• Completes concurrent secondary reviews of targeted patient populations to identify missed opportunities and accurate selection of principal diagnosis.
• Acts as liaison between the Coding Department and the Clinical Documentation Specialist to reconcile discrepancies in DRG assignment.
• Collaborates with CDI educator when specified educational needs are identified.
• Documents and tracks secondary review data.
• Shares this information with CDI Director and CDI Educator.
• Analyzes and interprets clinical data to identify gaps, inconsistencies, and/or opportunities for improvement in the clinical documentation and appropriately query the provider using a concurrent or retrospective query process.
• Follow up to ensure queries are answered.
• Assigns the appropriate DRG, MCCs and CCs to each record reviewed.
• Collaborates with other clinical disciplines and members of the coding department to ensure high quality clinical documentation and efficient, timely coding of the medical record.
• Collaborates with Coding Department when discrepancies in the medical record are identified and reviews medical record to provide clinical feedback for accurate coding of procedural codes, ICD-CM diagnosis or DRG.
• Develops collaborative relationships and promotes teamwork with coworkers and other departments.
• Organizes and performs work responsibilities effectively and efficiently.
• Maintains strict patient confidentiality, adhering to HIPPA guidelines.
• Demonstrates standards of performance (ownership, teamwork, communication, compassion) that support patient satisfaction and principles of service excellence.
• Performs other duties as assigned.

Benefits

• Great Place to Work certification
• Organizational culture that supports exceptional patient care
• Organizational culture that supports the well-being and professional growth of employees
• Opportunity to be part of a team where contributions are valued, growth is nurtured, and success is celebrated.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level