Job Description

Overview Your job is more than a job. The Clinical Documentation Improvement (CDI) Specialist facilitates complete and accurate documentation of medical records at the point of service, communicates with and educates medical staff members, coders, clinicians, and other facility employees regarding updates and guideline changes, and collaborates with physicians, case managers, coders, and other health team members to ensure documentation reflects clinical treatment, decisions, and diagnoses for inpatients and outpatients. Your Everyday Clinical Documentation Conducts reviews and analyses of health records for inpatient/outpatient encounters to identify relevant diagnoses. Provides direction for concurrent modification to clinical documentation to ensure appropriate coding for reimbursement and to reflect clinical severity and services provided to patients. Maintains accurate and complete documentation of clinical information used to measure and report physician and facility outcomes. Collaboration Collaborates with physicians/providers, nurses, and coding staff to improve quality and completeness of documentation. Queries physicians/providers to clarify ambiguous, conflicting, or incomplete documentation. Collaborates with interdisciplinary teams including Physician Advisors (PAD), physicians, nurse practitioners, PAs, mid-level practitioners, and department managers for Revenue Integrity, Coding, Data Quality, Case Management and Health Information Management. Education Provides ongoing education to all members of the patient care team. Facilitates modification to clinical documentation to ensure that the medical record presents an accurate patient clinical picture and intent of the provider. Oversees Reviews Conducts concurrent and retrospective review of medical records to increase the accuracy, clarity, and specificity of provider documentation. Metrics Accountable for attainment of goals and revenue cycle key performance indicators (KPIs) as defined by the department. Maintains communication with management on backlogs and stays informed of necessary situations as they relate to patients, physicians, and other healthcare providers. The Must-Haves Minimum Education/Experience Qualifications Combination Of Appropriate Education And Work Experience Is Required Bachelor’s Degree in Nursing or HIM 2 years of experience in Clinical / Nursing & Case Management or Coding with an Associate’s Degree Must have one of the following certifications/licensures: Licensed Registered Nurse/BSN, LPN (must be licensed in the state of Louisiana), Certified Clinical Documentation Specialist, RHIA, RHIT or Coding Certified from AHIMA/AAPC. Skills And Abilities Knowledge related to electronic health records, health information systems and healthcare applications and their effects on Coding practices today and in the future. High ethical standards. Knowledge of ICD-10-CM, ICD-10-PCS, CPT/HCPCS, MS-DRG, APR-DRG and APC coding guidelines. Extensive knowledge of hospital and professional coding including provider-based billing. Experience with concurrent reviews. Knowledge of medical terminology, classification systems and vocabularies. Knowledge of privacy and security regulations, confidentiality, laws, and release of information practices. Experience in identifying learning needs and providing education and training to support a learning organization. Strong Analytical Abilities And Problem-solving Skills. Excellent oral, written and interpersonal communication skills. Ability to organize and set priorities to meet objectives in a timely manner. Ability to adapt to change and handle challenges proactively and with poise. Ability to effectively collaborate with physicians and managerial staff at all levels. Work Shift Days (United States of America) LCMC Health is a community. Our people make health happen. While our NOLA roots run deep, our branches are the vessels that carry our mission of bringing the best possible care to every person and parish in Louisiana and beyond, with a culture of everyday extraordinary. This includes celebrating authenticity, originality, equity, inclusion, and a welcoming attitude. Your extras Deliver healthcare with heart. Give people a reason to smile. Put a little love in your work. Be honest and real, but with compassion. Bring some lagniappe into everything you do. Forget one-size-fits-all; think one-of-a-kind care. See opportunities, not problems – it’s all about perspective. Cheerlead ideas, differences, and each other. Love what makes you, you - because we do. You are welcome here. LCMC Health is an equal opportunity employer. All qualified applicants receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability status, protected veteran status, or any other characteristic protected by law. The above job summary is intended to describe the general nature and level of the work being performed by people assigned to this work. This is not an exhaustive list of all duties and responsibilities. LCMC Health reserves the right to amend and change responsibilities to meet organizational needs as necessary. Simple things make the difference. #J-18808-Ljbffr LCMC Health

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