Clinical Documentation Improvement Specialist II - Full Time

Clinical Documentation Improvement Specialist II

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.

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. 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.

Reports directly to the Director of CDI

Responsibilities and Duties:

• Completes concurrent secondary reviews of targeted patient populations to identify missed opportunities and accurate selection of principal diagnosis.
• Advanced clinical expertise and extensive knowledge of complex disease processes with a broad clinical experience in an inpatient setting required.
• Acts as liaison between the Coding Department and the Clinical Documentation Specialist to reconcile discrepancies in DRG assignment.
• Collaborates with CDI educator when specified educational needs are identified.
• Documents and tracks secondary review data. Shares this information with CDI Director and 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. Follow up to ensure queries are answered.
• Assigns the appropriate DRG, MCCs and CCs to each record reviewed.
• 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.
• 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.
• Develops collaborative relationships and promotes teamwork with coworkers and other departments.
• Organizes and performs work responsibilities effectively and efficiently.
• Maintains strict patient confidentiality, adhering to HIPPA guidelines.
• Demonstrates standards of performance (ownership, teamwork, communication, compassion) that support patient satisfaction and principles of service excellence.
• Performs other duties as assigned.

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:

• Doctor of Medicine (MD), Doctor of Osteopathy (DO), Foreign Medical Graduate (FMG), Physician Assistant (PA), or Registered Nurse/BSN
• RHIA, RHIT, or related clinical allied health degree
• Licensure / Certifications: CCS, CCDS, or CDIP required
• Experience: Minimum of 3 years' experience as a Clinical Documentation Specialist required.

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 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.