The Clinical Documentation Improvement Specialist facilitates the improvement of the overall quality, completeness, and accuracy of medical record documentation. The role promotes appropriate clinical documentation through extensive interaction with physicians and other members of the patient care team and coding staff to ensure documentation reflects the level of service, severity of illness, and is complete and accurate.
Reports directly to the Director of CDI.
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 ensures 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.
- Communicates 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 data reporting.
This position may require additional job-related tasks as assigned.
Requirements & Qualifications
Qualifications
- Must have one of the following certifications/licensures or related credentials: MD, DO, FMG, PA, RN/BSN, RHIA, RHIT, or a related clinical allied health degree.
- CDIP, CCDS, CCS, or equivalent certification is a plus.
- Minimum 1 year of clinical documentation or coding experience in an acute care setting.
- Knowledge of ICD-9 or ICD-10 coding.
- Strong computer skills preferred; coding training will be provided.
- Superior interpersonal skills and the ability to communicate effectively with physicians are essential.
Work Environment
- Ability to move about within and outside hospital properties for long periods of time.
- Ability 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 patients, families, peers, and medical personnel.
Location
Louisiana, US
Employment Type
Full-time
Experience Level
Associate
Remote work allowed
No
Posted
2 months ago