Clinical Documentation Specialist

Location: WK Medical Center Department: Clinical Documentation Improvement - CA-Clinical Documentation Improvement Classification: Full-Time Shift: 8:00 AM-5:00 PM Date Posted: 2/13/2023 Description: The Clinical Documentation Improvement Specialist (CDIS) is responsible for the evaluation of physician documentation and utilizing their clinical expertise to ensure the patients' severity of illness is accurately portrayed in the medical record for specificity of coding and increased coding accuracy. The CDIS ensures the accuracy and completeness of clinical information which is used for measuring and reporting physician and hospital outcomes. The CDIS also communicates with members of the medical staff on an ongoing basis to ensure that the documentation in the medical record adequately reflects the diagnoses being treated and the procedure performed. They also serve as a resource to physicians to help link ICD-10 coding guidelines and medical terminology to improve accuracy of patient severity of illness, risk of mortality, and final code assignment. An RN with a current license to practice as a professional nurse in the state of Louisiana will be required for this position.