Clinical Documentation Specialist - Health Information Management - Full-Time

Woman's Hospital • Baton Rouge, LA

406d • $62,400 - $91,520

About The Position

The Clinical Documentation Specialist at Woman's Hospital plays a crucial role in enhancing the quality and completeness of clinical documentation in medical records. This position involves ongoing collaboration with healthcare providers to ensure accurate representation of patient severity and services rendered, ultimately supporting correct diagnosis coding and compliance with healthcare standards.

Requirements

• Two-year associate degree or four-year bachelor's degree in nursing.
• Applicable clinical or professional certifications and licenses such as RHIT, RHIA, CCS, CPC, CCDS, CDIP, RN, LPN required.
• Minimum of two years related work experience in an acute care setting.
• Clinical, nursing, Health Information Management, and Clinical Documentation experience preferred.
• Proficiency in a medical record review.

Responsibilities

• Facilitates appropriate clinical documentation to support correct diagnosis coding and ensure the level of service rendered to all patients is documented.
• Communicates with physicians, nurse practitioners, case managers, coders, and other members of the care team to facilitate comprehensive medical record documentation.
• Assigns a working DRG and severity level using coding rules and guidelines with follow-up reviews as required by length of stay prior to discharge.
• Analyzes clinical information to identify areas within the chart for potential gaps in physician documentation.
• Queries physicians on a concurrent basis, monitors the query response from the physician, documents the physician response in 3M, and closes out the analyst's review if prior to discharge.
• Formulates credible clinical documentation clarifications to improve clinical documentation of principal diagnosis, co-morbidities, present on admission (POA), quality core measures, and patient safety indicators.
• Works with Physician Advisor and CDI Manager to resolve documentation discrepancies and clinical disparities.
• Monitors and tracks trends in clinical documentation, identifying areas for improvement and ensuring compliance with internal and external standards.

Benefits

• Competitive salary range of $30.00 - $44.00 per hour.
• Recognition as a Best Place to Work by Modern Healthcare for 17 consecutive years.
• Supportive organizational culture focused on exceptional patient care and employee satisfaction.

What This Job Offers

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