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The Clinical Documentation Improvement (CDI) Specialist facilitates complete and accurate documentation of medical records on an ongoing basis, at the point of service. To communicate and educate the medical staff members, coders, clinicians, and other facility employees regarding updates, guideline changes. Must communicate with physicians, case managers, coders, and other health team members to facilitate comprehensive medical record documentation to reflect clinical treatment, decisions, and diagnoses for inpatients and outpatients.

GENERAL DUTIES

Clinical Documentation:

Conducts reviews and analyses of health records for inpatient/outpatient and clinical encounters to identify relevant diagnoses. Provides direction for concurrent modification to clinical documentation to ensure appropriate coding for reimbursement for clinical severity and services provided to the patients. Maintains accurate and complete documentation of clinical information used to measure and report physician and facility outcomes.

Collaboration:

Collaborates extensively with physicians/providers, nurses, or other healthcare providers and coding staff to improve quality and completeness of documentation of care provided and coded. Queries physician/providers to clarify ambiguous, conflicting, or incomplete documentation. Collaborates with interdisciplinary teams including, but not limited to Physician Advisors (PAD), physicians, nurse practitioners, PA’s, mid-level practitioners, and the 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 the medical records to increase the accuracy, clarity, and specificity of provider documentation.

Metrics:

Accountable for attainment of goals and revenue cycle key performance indicators (KPI’s) as defined by the department. Maintains communication with management on backlogs and keeps abreast of necessary situations as it relates to patients, physicians, and any other healthcare providers.

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 as it relates to, but not limited to, electronic health record, 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/HCPS, 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, classifications systems and vocabularies.

Knowledge of privacy and security regulations, confidentiality, laws, access and release of information practices.

Experience in assisting and identifying learning needs as well as providing education and training designed 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 ensure objectives are met in a timely manner.

Ability to adapt to change and handle challenges proactively and with pose.

Ability to effectively collaborate with physicians and managerial staff at all levels.

REPORTING RELATIONSHIPS

• Does this position formally supervise employees? No

FUNCTIONAL DEMANDS

• Sedentary: Very light physical requirements- Sedentary Work- Exerting up to 10 pounds of force occasionally (occasionally means activity or conditions exist up to 1/3 of the work day), and/or, a negligible amount of force frequently (frequently means activity or condition exists from 1/3 to 2/3 of the work day) to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.

PHYSICAL DEMANDS

• Sitting - Continuous (67-100% of day)
• Standing - Occasional (0-35% of day)
• Walking - Occasional (0-35% of day)
• Climbing (e.g., stairs or ladders) - Occasional (0-35% of day)
• Lifting Floor to waist level: 0-10lbs - Occasional (0-35% of day)
• Lifting Floor to waist level: 10-20lbs - Occasional (0-35% of day)
• Lifting Floor to waist level: 20-50lbs - Occasional (0-35% of day)
• Lifting Floor to waist level: 50-100lbs - Occasional (0-35% of day)
• Lifting Floor to waist level: 100+lbs - Occasional (0-35% of day)
• Lifting Waist level and above: 0-10lbs - Occasional (0-35% of day)
• Lifting Waist level and above: 10-20lbs - Occasional (0-35% of day)
• Lifting Waist level and above: 20-50lbs - Occasional (0-35% of day)
• Lifting Waist level and above: 50-100lbs - Occasional (0-35% of day)
• Lifting Waist level and above: 100+lbs - Occasional (0-35% of day)
• Carrying objects - Occasional (0-35% of day)
• Wrist position deviation - Frequent (36-66% of day)
• Pinching/fine motor activities - Frequent (36-66% of day)
• Keyboard use/repetitive motion - Frequent (36-66% of day)
• Talk or hear - Continuous (67-100% of day)

SENSORY REQUIREMENTS

• Near Vision - Accurate 20/40
• Far Vision - Accurate 20/40
• Depth Perception - Minimal
• Hearing - Accurate

OCCUPATIONAL EXPOSURE RISK POTENTIAL

• Bloodborne pathogens - Not Anticipated
• Chemical - Not Anticipated
• Airborne communicable diseases - Not Anticipated
• Extreme temperatures - Not Anticipated
• Radiation - Not Anticipated
• Uneven surfaces or elevations - Not Anticipated
• Extreme noise levels - Not Anticipated
• Dust/particular matter - Not Anticipated
• Other (List) -

POPULATION SERVED

• Neonate/Infant up to 1 year: No
• Youth (1yr to 15 yrs): No
• Adult (16 and up): No

WORK SHIFT:

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 and put a little more heart and soul into healthcare along the way. Celebrating authenticity, originality, equity, inclusion and a little “come on in” attitude is the foundation of LCMC Health’s culture of everyday extraordinary

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.

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3.    To keep our career applications up-to-date, applications are inactive after 6 months and, therefore, require a new application for employment to be completed. 

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