Clinical Documentation Improvement Specialist - Full Time
Lake Charles Memorial Health System, Lake Charles, LA, United States
Overview
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.
Description Of 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.
SUPERVISION
Reports directly to the Director of CDI
Responsibilities And Duties
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.
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
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
Clinical Documentation Improvement Practitioner (CDIP), Certified Clinical Documentation Specialist (CCDS), Certified Coding Specialist (CCS), or equivalent is a plus
Minimum 1-year clinical documentation, coding experience in acute care setting.
Knowledge of ICD-9 or ICD-10 coding, as well as strong computer skills preferred, however content training in coding will be provided.
Work requires superior interpersonal skills and demonstrated ability to communicate effectively with physicians is essential.
Physical Demands / 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.
Experience Memorial is presented as a slogan and a commitment to care and community. At Lake Charles Memorial Health System you will be part of an organizational culture that supports patient care and the growth of employees. Join us and be part of a team where your contributions are valued, growth is nurtured, and success is celebrated.
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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.
Description Of 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.
SUPERVISION
Reports directly to the Director of CDI
Responsibilities And Duties
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.
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
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
Clinical Documentation Improvement Practitioner (CDIP), Certified Clinical Documentation Specialist (CCDS), Certified Coding Specialist (CCS), or equivalent is a plus
Minimum 1-year clinical documentation, coding experience in acute care setting.
Knowledge of ICD-9 or ICD-10 coding, as well as strong computer skills preferred, however content training in coding will be provided.
Work requires superior interpersonal skills and demonstrated ability to communicate effectively with physicians is essential.
Physical Demands / 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.
Experience Memorial is presented as a slogan and a commitment to care and community. At Lake Charles Memorial Health System you will be part of an organizational culture that supports patient care and the growth of employees. Join us and be part of a team where your contributions are valued, growth is nurtured, and success is celebrated.
#J-18808-Ljbffr