Ensure that our documentation is accurate and experience an exceptional career setting.
Here is your opportunity to build a satisfying career with a renowned organization featuring a state-of-the-art facility. Lakeland Regional Health is a nationally recognized, not-for-profit healthcare system located in central Florida. Our 849-bed Lakeland Campus is one of the largest hospitals in the state and operates the nation's busiest emergency department. Committed to treating patients and professionals with the kindness and respect we all deserve, we have earned the Great Workplace Award from Gallup as well as inclusion among the list of America's Best Mid-Size Employers by Forbes.
Growth and Opportunity
100 years of stability
If you would like the chance to do work that is meaningful and rewarding, join us as:
Clinical Documentation Specialist II Lakeland Medical Center Shift: Monday - Friday
Reporting to the manager of Coding and Clinical Documentation Improvement, the professional we select will review patient records to improve documentation and accurately reflect the severity of illness and intensity of service. Communicating with physicians, this person will collaborate with the HIM director, HIM coders, and the physician advisor to ensure accurate coding; improve the quality of DRG-related documentation; and decrease the risk of mortality, severity of illness, and case-mix index. Following our philosophy of People at the Heart of All We Do, this person will participate in the education of physicians through lunch-and-learn sessions and on an as-needed basis.
Additional responsibilities include:
Participating in team development, achievement of dashboards, and accomplishment of department goals and objectives.
Collaborating with the healthcare team to facilitate documentation within the medical record that supports patients’ severity of illness and risk of mortality.
Reviewing clinical issues with the coding team as needed to ensure appropriate MSDRG/APR-DRG.
Conducting initial and extended-stay concurrent reviews on all selected admissions to clarify documentation in the medical record.
Serving as a resource for physicians and teaching them to improve their documentation so it more accurately reflects intensity of services/severity of illness.
Identifying the need to clarify documentation in records, and conducting follow-up on unanswered queries during the patient stay to obtain responses to open queries.
Ensuring the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes, including Present On Admission (POA), Patient Safety Indicators (PSI), and Hospital-Acquired Conditions (HAC).
Educating internal customers on clinical documentation opportunities, coding and reimbursement issues, and performance-improvement methodologies.
Assisting in the development of clinical documentation training for medical staff, UR/clinical resource coordinators, nursing and coders to ensure compliance with OIG, CMS, and other regulations.
Interacting with the physician advisor, HIM director, HIM coding staff, compliance officer, quality improvement coordinators, department managers, information system staff, and patient financial staff on a regular basis to identify and assist in resolving documentation issues.
Education, Experience, and Licensure
Successful applicants will each possess an associate’s degree and acute clinical documentation-improvement experience within the past 10 years. Other essentials include CCS or CDIP; experience with ICD-10-CM, and documentation review and DRG analysis OR experience with clinical documentation reviews of clinical indicators and knowledge of specificity requirements; and experience interacting with and educating medical staff and clinical support staff. Master’s degree preferred.
Zero-deductible/zero-co-pay medical coverage with LRH providers