CDI Specialist RN
Lexington Medical Center – Lexington Health – Lexington, South Carolina
Full‑time position. Seniority level: Associate.
Lexington Health is a comprehensive network of care that includes six community medical and urgent care centers, nearly 80 physician practices, a 607‑bed teaching hospital, and is a recognized employer for excellence in nursing care.
Job Summary
Provides thorough concurrent review of medical record clinical documentation to capture documented and potential principal diagnosis, secondary diagnoses and procedures affecting DRG assignment and profiling outcomes. Queries the medical staff and other caregivers as necessary to obtain accurate and complete physician documentation that supports DRG assignment and the severity of patient illness and risk of mortality.
Minimum Qualifications
Associate’s Degree in Nursing
3 Years of Clinical Experience in an Acute Care Setting
Current RN License to Practice in South Carolina. Must hold or obtain one of the following certifications within 2 years: ACDIS (Certified Clinical Documentation Specialist), AHMIA (Certified Documentation Improvement Practitioner)
Preferred: 3 years of Acute care experience; Current or previous inpatient CDI experience
Essential Functions
Collaborates with physician, physician extender, nurse, case manager/utilization reviewer and Medical Records coder to identify principal diagnosis options, secondary diagnoses and procedures, and assign working DRGs for identified populations.
Identifies need to clarify documentation in records and utilizes strong communication skills with healthcare professionals to capture needed documentation.
Conducts thorough medical record review on initial and extended‑stay concurrent reviews for all selected inpatient admissions, documenting findings to support patient’s severity of illness and risk of mortality.
Maintains complete confidentiality of patient information.
Ensures documentation is accurate, complete and compliant, supporting acute or chronic conditions and medical necessity.
Duties & Responsibilities
Develop and sustain positive working relationships with providers, advanced practice providers, administrators, peers, and other collaborating departments.
Prioritize tasks with workflow.
Stay up to date with industry standards by participating in continuing education related to ACDIS, ICD‑10‑CM coding, ICD‑10‑PCS coding, AHA Coding Clinics, and CMS Official Coding Guidelines.
Utilize software, programs, and other technology tools to prioritize and maintain workflow.
Performs all other duties as assigned.
Benefits
Day ONE medical, dental and life insurance benefits
Health care and dependent care flexible spending accounts (FSAs)
403(b) match plan; LHI matches dollar for dollar up to 6%
Employer‑paid life insurance – equal to 1x salary
Supplemental life insurance – up to 3x salary
Adoption assistance
Short‑term and long‑term disability coverage after 90 days of eligible employment
Student loan forgiveness
Equal Opportunity Employer
It is the policy of Lexington Health to provide equal opportunity of employment for all individuals, and to remain compliant with applicable state and federal laws and regulations. Lexington Health strives to provide a discrimination‑free environment, and to recruit, select, on‑board, and employ all employees without regard to race, color, religion, sex, age, disability, national origin, veteran status, or pregnancy, childbirth, or related medical conditions, including but not limited to lactation. Lexington Health endeavors to promote employees from within the hospital where possible and in accordance with the employee’s desires and abilities and the hospital’s needs.