Responsible for assessing, planning, implementing, coordinating, monitoring, and evaluating physical and psychological factors.
Works collaboratively with Medical Staff, Nursing Staff and other patient care givers to improve the quality of chart documentation to accurately reflect patient severity and complexity of treatment.
Perform initial case review and appropriate follow-up reviews based on judgment of clinical picture.
Educational and/or Professional Qualifications:
1.
Must have one of the following certifications: Registered Nurse (RN), Licensed Practical Nurse (LPN), Respiratory Therapist (RRT or CRT), Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), or Certified Coding Specialist (CCS).
Previous Experience:
1.
One of the following is required:
A.
If RN or LPN, RRT, or CRT must have a minimum of 3 years clinical nursing experience.
B.
If Coder, must have a minimum of 3 years coding experience.
2.
A minimum of 3 years of experience as a Clinical Documentation Improvement Specialist is preferred.
2.
Previous experience in Quality Resource Management desirable.
Other Special Training/Skills:
1.
Knowledge of care delivery documentation systems and related medical record documents.
2.
Knowledge of elements of disease processes and related procedures.
3.
Thorough, up-to-date clinical skills.
4.
Current working knowledge of medical terminology, coding, pathophysiology, anatomy and physiology, pharmacology, surgical procedures, etc.
3.
Experience working directly with physicians.
4.
Excellent communication and negotiation skills are essential.
5.
Ability to prioritize responsibilities and use appropriate time management skills.
Licensure, Certification, Registration, etc.
:
1.
National coding certification desired (AHIMA’s RHIA, RHIT, CCS, CDIP preferred)
2.
Current license as a Registered Nurse or a Licensed Practical Nurse in the State of Louisiana.
3.
National Clinical Documentation Certification Desired (ACDIS’s CCDS)
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