Clinical Document Improvement Specialist RN (Full Time)

DESCRIPTION OF POSITION:

• The Clinical Documentation Nurse facilitates the improvement of the overall quality, completeness and accuracy of medical record documentation. To obtain and promote appropriate clinical documentation through extensive interaction with physicians and other members of the patient care team and coding staff. To ensure Clinical Documentation reflects the level of service, severity of illness and is complete and accurate.

SUPERVISION : Reports directly to the Director of Case Management

RESPONSIBILITIES AND DUTIES:

• 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 assure any clarification is noted in the patient record according to policy.
• Maintains a 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.
• Relates 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 finally data reporting.

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.

EDUCATION AND WORK EXPERIENCE

• Graduate of an approved school of Nursing.
• Basic computer skills.
• Current licensure to practice professional nursing in Louisiana or multi-state compact license.
• Must maintain required hours of in-service per year to meet requirements for CEs.
• CPR certification.
• Ability to read, write and speak intelligible English.

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.

Working at Lake Charles Memorial Health System | Great Place To Work®