Clinical Documentation Specialist I

Imagine a career at one of the nation's most advanced health networks.

Be part of an exceptional health care experience. Join the inspired, passionate team at Lehigh Valley Health Network, a nationally recognized, forward-thinking organization offering plenty of opportunity to do great work.

LVHN has been ranked among the "Best Hospitals" by U.S. News & World Report for 23 consecutive years. We're a Magnet(tm) Hospital, having been honored five times with the American Nurses Credentialing Center's prestigious distinction for nursing excellence and quality patient outcomes in our Lehigh Valley region. Finally, Lehigh Valley Hospital - Cedar Crest, Lehigh Valley Hospital - Muhlenberg, Lehigh Valley Hospital- Hazleton, and Lehigh Valley Hospital - Pocono each received an 'A' grade on the Hospital Safety Grade from The Leapfrog Group in 2020, the highest grade in patient safety. These recognitions highlight LVHN's commitment to teamwork, compassion, and technology with an unrelenting focus on delivering the best health care possible every day.

Whether you're considering your next career move or your first, you should consider Lehigh Valley Health Network.

Summary
Responsible for improving the overall quality and completeness of clinical documentation in the medical record to reflect the severity of illness, clinical treatment, decisions and diagnoses of patients. This position involves concurrent medical record review, DRG validation, querying providers, capture of clinical and quality indicators to ensure the thoroughness of documentation prior to coding and billing.

Job Duties

• Responsible for the day-to-day review and evaluation of clinical documentation by the Medical Staff and healthcare team in accordance with the network's designated clinical documentation policies and procedures. Calculates working DRG within CDI tracking systems/software. Performs follow-up on cases through patient discharge.
• Applies clinical knowledge and experience to the daily review and evaluation of the medical record including physician/clinical documentation, lab results, diagnostic information and treatment plans.
• Promotes integrity of clinical documentation and thoroughness of the medical record to ensure appropriate severity of illness, risk of mortality, length of stay and reimbursement are captured.
• Communicates with providers via verbal and/or electronic clinical documentation integrity queries to clarify missing, unclear or conflicting medical record documentation; identifies opportunities for service line and individual provider education and communicates to CDI leadership.
• Achieves key performance indicators in the areas of productivity/thoroughness and quality.

Minimum Qualifications

• Bachelor’s Degree BSN, RHIA or
• Master’s Degree CRNP, PA-C or
• Associate’s Degree RN, RHIT or
• Specialized Diploma RN, CCS, CPC
• 5 years advanced coding or clinical experience in an acute care hospital setting or
• 1 year CDI or coding experience.
• Experience with medical record reviews and/or DRG validation.
• Proficient in MS Outlook, Word, Excel and PowerPoint.
• Ability to acquire working knowledge of DRG assignment and methodology, coding practices and clinical documentation requirements.
• Will demonstrate adaptability and self-motivation to stay abreast of CMS rules and regulations; incorporate those changes into daily practice; maintain knowledge of federal, state and private payor regulations and demonstrate knowledge and understanding of ICD-10 Coding Guidelines.
• Will demonstrate accountability, professional development, and adhere to departmental policies and guidelines.
• RHIT - Registered Health Information Technician - American Health Information Management Association Upon Hire or
• RN - Licensed Registered Nurse_PA - State of Pennsylvania Upon Hire or
• RHIA - Registered Health Information Administrator - American Health Information Management Association Upon Hire or
• CPC - Certified Professional Coder - American Academy of Professional Coders Upon Hire or
• CCS - Certified Coding Specialist - American Health Information Management Association Upon Hire

Physical Demands
Lift and carry 7 lbs., continuous sitting >67%, frequent keyboard use/repetitive motion, frequent fine motor activity/wrist position deviation.

Job Description Disclaimer: This position description provides the major duties/responsibilities, requirements and working conditions for the position. It is intended to be an accurate reflection of the current position, however management reserves the right to revise or change as necessary to meet organizational needs. Other responsibilities may be assigned when ci