FMOL Health · 21 hours ago
Clinical Documentation Specialist
Baton Rouge, LA
Full-time
Onsite
Mid, Senior Level
3+ years expFMOL Health is focused on improving healthcare documentation accuracy and compliance. The Clinical Documentation Specialist (CDS) reviews medical records, collaborates with clinicians for clarity, and ensures adherence to regulatory guidelines while supporting operational improvements.
Health Care
Responsibilities
Documentation Review
Performs assigned CDI reviews of inpatient medical records with concentration on review priority as designated (such as those payors with prospective payment methodology)
Performs accurate and thorough initial and follow up CDI medical record reviews as assigned, within productivity standards
Documents CDI review findings, following processes and guidelines
Submits queries to physicians, seeking clarity on significant diagnoses, procedures, complications and/or co-morbidities, as indicated, in order to facilitate a comprehensive, clear and complete medical record
Consistently demonstrates accurate data entry regarding CDI activity, contributing to efficiency and accuracy of CDI metrics and initiatives
Operates within the compliance guidelines of Medicare and Medicaid Services
Considers compliance and displays ethical decision-making skills
Understands and complies with policies and procedures related to confidentiality of medical records
Demonstrates actions consistent with FMOLHS Mission, core values and service standards as daily duties are performed
Demonstrates standards of performance that support patient satisfaction, principles of service excellence, all applicable laws, regulatory agencies and accrediting bodies
Facilitates accuracy and completeness of documentation used for measuring and reporting provider and hospital outcomes
Maintains accurate and complete record review and query outcome to comply with departmental and regulatory guidelines
Collaborates with physicians and other clinical disciplines to clarify clinician documentation, which is incomplete, conflicting, or non-specific
Educates physicians and other clinical disciplines on best documentation practices, in conjunction with CDI and Coding leadership, as well as physician advisors
Serves as a resource to clinicians for linking medical terminology and coding guidelines for improved accuracy in code assignment
Assists with communication between coders and physicians for retrospective querying
Collaborates with Health Information Management regarding coding analysis and education initiatives for physicians and other clinical disciplines
Consults with leadership and/or other clinical disciplines in matters of uncertainty
Demonstrates standards of performance that support patient satisfaction and principles of service excellence
Communicates effectively with other team members, physicians and customers while always remaining tactful and friendly
Participates in CDI program related meetings, clinician education, staff development, departmental activities, and opportunities
Demonstrates knowledge of ICD-10 Official Coding Guidelines, and ability to interpret documentation for appropriate working codes, resulting in the correct working DRG assignment
Demonstrates ability to interpret medical record documentation to determine the appropriate principal diagnosis and procedure, resulting in the appropriate DRG
Demonstrates ability to correlate clinical information/ detail and medical record documentation terminology for appropriate documentation clarification opportunities
Demonstrates knowledge of diagnosis specificity clarification opportunities, which could result in greater specificity and accuracy in code assignment
Initiates appropriate and accurate documentation clarification requests (queries), facilitating modifications to the medical record documentation for accurate reflection of the patient' s severity of illness, risk of mortality and resource utilization
Maintains knowledge relevant to role in CDI, including participating in professional development and developing expertise
Serves as resource to CDI team members, including participation in projects
Qualification
Required
RN with 3 or more years of clinical nursing experience in an acute care setting
RHIA or RHIT with 5 or more years of inpatient (acute care) ICD 10 coding experience
Graduated from an accredited school of nursing or Associate in Nursing or HIM
RN Nurse Licensure Compact (NLC), Louisiana licensed RN and/or Mississippi licensed RN
Preferred
RHIA with CCS Certification
RHIT with CCS Certification
Company
FMOL Health
FMOL Health is a bold, connected health system that delivers care that prioritizes people – every patient, every community, every time – while honoring the unique character of each market we serve.
10001+ employees
H1B Sponsorship
FMOL Health has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2025 (48)
2024 (30)
2023 (25)
2022 (36)
Funding
Current Stage
Late StageLeadership Team
Richard R. Vath
Interim President and CEO
Eric Clay
Vice President and Chief Security Officer
Recent News
Franciscan Missionaries of Our Lady Health System
2025-11-03
2025-10-11
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