Clinical Documentation Improvement Specialist - Full Time

Lake Charles Memorial Hospital • Lake Charles, LA

1d • Onsite

About The 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.

Requirements

• 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
• Minimum 1-year clinical documentation, coding experience in acute care setting.
• Work requires superior interpersonal skills and demonstrated ability to communicate effectively with physicians is essential.

Nice To Haves

• Clinical Documentation Improvement Practitioner (CDIP), Certified Clinical Documentation Specialist (CCDS), Certified Coding Specialist (CCS), or equivalent is a plus
• Knowledge of ICD-9 or ICD-10 coding, as well as strong computer skills preferred, however content training in coding will be provided.

Responsibilities

• 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.

Benefits

• 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.
• Contributions are valued, growth is nurtured, and success is celebrated.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree