The Clinical Documentation Improvement Specialist improves the overall quality, completeness, and accuracy of medical record documentation. This role works closely with physicians, the patient care team, and coding staff to ensure documentation accurately reflects severity of illness, level of service, and overall patient care.
Responsibilities
- Concurrently review inpatient admissions to identify opportunities to improve documentation quality.
- Comply with relevant policies, procedures, guidelines, and regulatory, compliance, and accreditation standards.
- Initiate physician interaction to clarify ambiguous or conflicting documentation and ensure clarification is documented according to policy.
- Maintain positive and open communication with physicians, patient care team members, and coding staff.
- Participate in workshops, conferences, and in-services to support professional development.
- Explain the impact of complete documentation on coding quality, DRG assignment, physician profiling, case mix index, and expected mortality rates.
- Stay current with coding guidelines, compliance, reimbursement, and other regulatory updates.
- Understand the flow of health information from medical record documentation through discharge, coding, billing, and data reporting.
This position reports directly to the Director of CDI.
Requirements & Qualifications
Qualifications
- One of the following credentials or licensures is required: 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 of 1 year of clinical documentation or coding experience in an acute care setting.
- Knowledge of ICD-9 or ICD-10 coding preferred.
- Strong computer skills preferred.
- Excellent interpersonal and communication skills, with the ability to work effectively with physicians.
Work Environment
- Must be able to move about within and outside hospital properties for extended periods.
- Must be able to respond quickly and effectively to emergency and non-emergent situations.
- May be required to assist with 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
1 month ago