Clinical Documentation Improvement Specialist II - Full Time
Lake Charles Memorial Health System, Lake Charles, LA, United States
Description Of Position
The Clinical Documentation Improvement Specialist II is an experienced, certified CDI with a broad clinical knowledge base and understanding of DRG documentation requirements who works under the supervision of the CDI Director and in collaboration with the CDI Educator.
SUPERVISION
Reports directly to the Director of CDI.
Responsibilities and Duties
Improves capture of additional comorbid conditions to include HAC's and focused PSI diagnoses.
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 queries the provider using a concurrent or retrospective query process. Follows 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 HIPAA guidelines.
Demonstrates standards of performance (ownership, teamwork, communication, compassion) that support patient satisfaction and principles of service excellence.
Performs other duties as assigned.
The above statements are only meant to be a representative summary of the major duties and responsibilities performed by incumbents of this job. The incumbents may be requested to perform job‑related tasks other than those stated in this description.
Certification, Registration, or Licensure 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
Licensure / Certifications: CCS, CCDS, or CDIP required
Minimum of 3 years’ experience as a Clinical Documentation Specialist required.
Physical Demands and Work Environment
Work requires a variety of physical activities, including moving about within and outside of all hospital properties for long periods of time.
Must be able to respond quickly and effectively to emergency and non‑emergent situations.
May be required to assist in controlling disorderly conduct or combative patients.
Must be able to exchange accurate information with patient, family, peers and medical personnel.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
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The Clinical Documentation Improvement Specialist II is an experienced, certified CDI with a broad clinical knowledge base and understanding of DRG documentation requirements who works under the supervision of the CDI Director and in collaboration with the CDI Educator.
SUPERVISION
Reports directly to the Director of CDI.
Responsibilities and Duties
Improves capture of additional comorbid conditions to include HAC's and focused PSI diagnoses.
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 queries the provider using a concurrent or retrospective query process. Follows 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 HIPAA guidelines.
Demonstrates standards of performance (ownership, teamwork, communication, compassion) that support patient satisfaction and principles of service excellence.
Performs other duties as assigned.
The above statements are only meant to be a representative summary of the major duties and responsibilities performed by incumbents of this job. The incumbents may be requested to perform job‑related tasks other than those stated in this description.
Certification, Registration, or Licensure 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
Licensure / Certifications: CCS, CCDS, or CDIP required
Minimum of 3 years’ experience as a Clinical Documentation Specialist required.
Physical Demands and Work Environment
Work requires a variety of physical activities, including moving about within and outside of all hospital properties for long periods of time.
Must be able to respond quickly and effectively to emergency and non‑emergent situations.
May be required to assist in controlling disorderly conduct or combative patients.
Must be able to exchange accurate information with patient, family, peers and medical personnel.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
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