Clinical Documentation Specialist

2 weeks ago


Lafayette, United States Franciscan Missionaries of Our Lady Health System Full time
Job Description

At Our Lady of Lourdes we offer you much more than just a job in the healthcare industry. We offer career opportunities for people who have a calling to share their gifts and talents as part of our healing ministry. As a Catholic hospital, we are here to create a spirit of healing - and we invite you to join our team today if you would like to be part of that spirit. In addition to competitive salaries and generous benefits, we offer you something special - the chance to do God's work by helping to serve people in need throughout our community, every day. #CB

Job Summary: The Clinical Documentation Specialist (CDS) is responsible for improving the overall accuracy and completeness of clinical documentation within the medical record. The CDS performs record reviews on selected medical records and documents findings and opportunities. Requests clarification of clinician documentation, which is incomplete, conflicting or non-specific. Facilitates modifications to medical record documentation for accurate reflection of the patient's severity of illness, risk of mortality, and resource utilization through interaction with clinicians, medical record coders, and multidisciplinary healthcare team. Serves as a resource to providers for linking medical terminology and coding guidelines for improved accuracy in code assignment. Facilitates accuracy and completeness of documentation used for measuring and reporting provider and hospital outcomes. Maintains accurate and complete record review and query outcome to comply with departmental and regulatory guidelines. Understands and complies with policies and procedures related to confidentiality of medical records. Identifies opportunities for intradepartmental and interdepartmental operational improvements. Participates in CDI program related meetings, clinician education, staff development, departmental activities and opportunities. Consistently demonstrates actions and values of the FMOLHS Mission as daily duties are performed

Requirements:
  • Must possess one of the following experience requirements: 1. RN with 3 years clinical nursing experience in an acute care facility or 2. RHIA or RHIT with 5 years acute care coding experience with CCS certification. or 3. 10 years acute care coding experience with CCS certification.
  • Associate's or Bachelor's degree in nursing or HIM preferred
  • Knowledge of ICD-9 coding or Documentation improvement experience preferred, but not required.
  • Louisiana licensed RN or RHIA with CCS or RHIT with CCS


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