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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.

DESCRIPTION OF POSITION:<ul><li>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.</li></ul>SUPERVISION: Reports directly to the Director of CDIRESPONSIBILITIES AND DUTIES:<ul><li>Concurrently reviews inpatient admissions to identify opportunities to improve the quality of documentation.</li><li>Complies with all relevant policies, procedures, guidelines and other regulatory, compliance and accreditation standards.</li><li>Initiates physician interaction to clarify ambiguous or conflicting documentation and assure any clarification is noted in the patient record according to policy.</li><li>Maintains positive and open communication with physicians, members of the patient care team, and coding staff.</li><li>Assumes responsibility for professional development by participating in workshops, conferences and/or in-services.</li><li>Relates the importance of complete documentation on coding quality, DRG assignment, physician profiling, case mix index and expected mortality rates.</li><li>Keeps current with changes in coding guidelines, compliance, reimbursement, and other relevant regulatory updates.</li><li>Understands the general flow of health information from medical record documentation and discharge, coding, billing and finally data reporting.</li></ul>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<ul><li>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</li><li>Clinical Documentation Improvement Practitioner (CDIP), Certified Clinical Documentation Specialist (CCDS), Certified Coding Specialist (CCS), or equivalent is a plus</li><li>Minimum 1-year clinical documentation, coding experience in acute care setting.</li><li>Knowledge of ICD-9 or ICD-10 coding, as well as strong computer skills preferred, however content training in coding will be provided.</li><li>Work requires superior interpersonal skills and demonstrated ability to communicate effectively with physicians is essential.</li></ul>Physical Demands/Work Environment<ul><li>Work requires a variety of physical activities, including moving about within and outside of all hospital properties for long periods of time.</li><li>Must be able to respond quickly and effectively to emergency and non-emergent situations.</li><li>May be required to assist in controlling disorderly conduct or combative patients.</li><li>Must be able to exchange accurate information with patient, family, peers and medical personnel.</li><li>Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions</li></ul>“Experience Memorial” is more than a slogan, it’s the care we provide our patients and it’s the commitment to our community and our team members. As a nationally certified Great Place to Work, at Lake Charles Memorial Health System you will have 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. Join us and be a part of a team where your contributions are valued, your growth is nurtured, and your success is celebrated.<a href="https://www.greatplacetowork.com/certified-company/7056608" rel="nofollow noopener noreferrer" target="_blank">Working at Lake Charles Memorial Health System | Great Place To Work?</a>

Lake Charles Memorial Health System

Clinical Documentation Improvement Specialist - Full Time

Billing

Certified Coding Specialist (CCS)

Clinical Study Publications

Communication Skills

Conferences

Documentation

Hospital

Interpersonal Skills

Medical Coding

Medical Records

Organizational Culture

Osteopathy

Patient Admissions

Patient Care

Physical Demands

Physician Assistant

Physician Credential

Quality Management

Registered Health Information Administrator (RHIA)

Registered Health Information Technician (RHIT)

Registered Nurse (RN)

clearcompany

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. 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.

DESCRIPTION OF POSITION:<ul><li>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.</li><li>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.</li><li>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; collaborating with Quality team, Case Managers and Coding department to assure documentation is clinically appropriate, accurately reflects the severity of illness for the patient, and is reflective of current CMS standards..</li></ul>SUPERVISION: Reports directly to the Director of CDIRESPONSIBILITIES AND DUTIES:<ul><li>Completes concurrent secondary reviews of targeted patient populations to identify missed opportunities and accurate selection of principal diagnosis.</li><li>Advanced clinical expertise and extensive knowledge of complex disease processes with a broad clinical experience in an inpatient setting required.</li><li>Acts as liaison between the Coding Department and the Clinical Documentation Specialist to reconcile discrepancies in DRG assignment.</li><li>Collaborates with CDI educator when specified educational needs are identified.</li><li>Documents and tracks secondary review data. Shares this information with CDI Director and CDI Educator</li><li>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.</li><li>Assigns the appropriate DRG, MCCs and CCs to each record reviewed.</li><li>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.</li><li>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.</li><li>Develops collaborative relationships and promotes teamwork with coworkers and other departments.</li><li>Organizes and performs work responsibilities effectively and efficiently.</li><li>Maintains strict patient confidentiality, adhering to HIPPA guidelines.</li><li>Demonstrates standards of performance (ownership, teamwork, communication, compassion) that support patient satisfaction and principles of service excellence.</li><li>Performs other duties as assigned.</li></ul>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<ul><li>Doctor of Medicine (MD), Doctor of Osteopathy (DO), Foreign Medical Graduate (FMG), Physician Assistant (PA), or Registered Nurse/BSN</li><li>RHIA, RHIT, or related clinical allied health degree</li><li>Licensure / Certifications: CCS, CCDS, or CDIP required</li><li>Experience: Minimum of 3 years’ experience as a Clinical Documentation Specialist required.</li></ul>Physical Demands/Work Environment<ul><li>Work requires a variety of physical activities, including moving about within and outside of all hospital properties for long periods of time.</li><li>Must be able to respond quickly and effectively to emergency and non-emergent situations.</li><li>May be required to assist in controlling disorderly conduct or combative patients.</li><li>Must be able to exchange accurate information with patient, family, peers and medical personnel.</li><li>Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions</li></ul>“Experience Memorial” is more than a slogan, it’s the care we provide our patients and it’s the commitment to our community and our team members. As a nationally certified Great Place to Work, at Lake Charles Memorial Health System you will have 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. Join us and be a part of a team where your contributions are valued, your growth is nurtured, and your success is celebrated.<a href="https://www.greatplacetowork.com/certified-company/7056608" rel="nofollow noopener noreferrer" target="_blank">Working at Lake Charles Memorial Health System | Great Place To Work?</a>

Clinical Documentation Improvement Specialist II - Full Time

Analysis Skills

Case Management

Clinical Data

Clinical Medicine

Clinical Validation

Content Management Systems (CMS)

Diagnosis-Related Group (DRG)

Disease

HIPAA (Health Insurance Portability and Accountability Act)

Healthcare Quality

Identify Issues

International Classification of Diseases (ICD)

Knowledge Base

Medicine

Patient Confidentiality

Reconciliation

Team Player

Time Management

Training/Teaching

Collaborate with CDI Director and other clinicians to facilitate the ongoing relevance of department specific orientation content, educational materials and documentation tip sheets and training programs/resources. Qualified individuals must have the ability to perform the following duties: Work with program leadership to plan, develop, and implement clinical documentation education programs for CDI specialists and providers.

DESCRIPTION OF POSITION:<ul><li>Work with program leadership to plan, develop, and implement clinical documentation education programs for CDI specialists and providers. Educate members of the CDI team on the review functions within the CDI program to meet and maintain enterprise goals and objectives, regulatory compliance, policies and procedures and personnel management.</li></ul>SUPERVISION: Reports directly to the Director of CDIRESPONSIBILITIES AND DUTIES:The percentage of time spent performing essential functions is 95%. Qualified individuals must have the ability to perform the following duties:<ul><li>Work with program leadership to plan, develop, and implement clinical documentation education programs for CDI specialists and providers.</li><li>Audits case reviews and queries of Clinical Documentation Specialists (CDIS) to ensure quality and compliance, using audit tools developed</li><li>Tracks, trends, and reports audit findings for each Clinical Documentation Specialist (CDIS) to Director/management team</li><li>Identifies knowledge gaps and provide clear explanations and interpretations on missing, unclear, conflicting, or non-compliant information captured by the CDIS</li><li>Researches, investigates, and remains up to date on both clinical and coding guidelines in quarterly Coding Clinics as they relate to physician documentation improvement needed, in an ICD-10 coding environment</li><li>Assists in overall quality, timeliness, and completeness of the quality health record to ensure appropriate data, provider communication, and quality outcomes</li><li>Responsible for using audit tools to conduct clinical quality audits</li><li>Develops and updates policies and procedures around the CDIS audit function; and refine audit tools as needed in collaboration with Director/management team</li><li>Will be responsible with working with CDI Leadership to mentor/train new CDI based on CDI orientation procedures</li><li>Analyze data to ascertain where stronger education is needed for both providers and staff</li><li>Serve as a mentor, resource for appropriate clinical documentation and educate CDI staff</li><li>Conduct individual and large group educational sessions for all CDI Specialists and/or providers.</li><li>Collaborate with CDI Director and other clinicians to facilitate the ongoing relevance of department specific orientation content, educational materials and documentation tip sheets and training programs/resources.</li></ul>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<ul><li>Must have one of the certifications/licensures: Licensed Registered Nurse/BSN, Medical Graduate, Physician Assistant</li><li>At least one of the following is required: CCS, CCDS, CDIP, RHIA or RHIT; preferably AHIMA or ACDIS Approved CDI Trainer</li><li>Minimum 3 years CDI experience in an acute care setting. Teaching or training experience is a plus.</li><li>Knowledge of ICD-10-CM, ICD-10-PCS, CPT/HCPS, MS-DRG, APR-DRG and APC coding guidelines</li><li>Advanced clinical expertise and extensive knowledge of complex disease processes with a broad clinical experience in an inpatient setting required.</li><li>Demonstrated competency in teaching/learning process, organizational skills and computer literacy required.</li><li>Excellent communication skills and professional demeanor is required.</li><li>Ability to perform computer data entry (Experience with Word, Excel)</li><li>Ability to utilize EHR and entry of data in CDI software, including reconciliation and reporting of data</li><li>Ability to build presentations/present Clinical Documentation Improvement to providers fluently</li><li>Ability to work with CDI and/or Coding staff with ongoing education.</li><li>Ability to train and mentor new CDI staff with onboarding and education</li></ul>Physical Demands/Work Environment<ul><li>Work requires a variety of physical activities, including moving about within and outside of all hospital properties for long periods of time.</li><li>Must be able to respond quickly and effectively to emergency and non-emergent situations.</li><li>May be required to assist in controlling disorderly conduct or combative patients.</li><li>Must be able to exchange accurate information with patient, family, peers and medical personnel.</li><li>Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions</li></ul>“Experience Memorial” is more than a slogan, it’s the care we provide our patients and it’s the commitment to our community and our team members. As a nationally certified Great Place to Work, at Lake Charles Memorial Health System you will have 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. Join us and be a part of a team where your contributions are valued, your growth is nurtured, and your success is celebrated.<a href="https://www.greatplacetowork.com/certified-company/7056608" rel="nofollow noopener noreferrer" target="_blank">Working at Lake Charles Memorial Health System | Great Place To Work?</a>

Clinical Documentation Improvement Educator - Full Time

Acute Care

Auditing

Clinical Outcomes

Clinical Practices/Protocols

Clinical Training

Computer Skills

Data Analysis

Data Entry

ICD-10

Leadership

Maintain Compliance

Medical Record System

Mentoring

Microsoft Excel

Microsoft Word

Organizational Skills

People Management

Policy Development

Presentation/Verbal Skills

Procedure Development

Program Planning

Regulatory Compliance

Staff Training

Training Program

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Clinical Documentation Improvement Specialist - Full TimeLake Charles Memorial Health System

Clinical Documentation Improvement Specialist II - Full TimeLake Charles Memorial Health System

Clinical Documentation Improvement Educator - Full TimeLake Charles Memorial Health System

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