Clinical Documentation Specialist (LPN)

Job ID
Clinical - All


Provides assessment of all medical record documentation to ensure that a complete and thorough accounting of the patient's status of health/severity of illness is captured and to ensure the coding within the medical record is comprehensive and complete.


Supports Clinical Health Services, Nurse Practitioners, Service Center staff through compliant communication regarding the clinical documentation of a member visit  using a diverse set of concurrent medical record review skills, clinical knowledge, and knowledge of coding and reimbursement regulations.


Principal Responsibilities

  • Ability to recognize opportunities to clarify the etiology of symptoms
  • Ability to interpret medication administration record to look for query opportunities.
  • Ability to interpret laboratory and radiology results to look for query opportunities
  • Ability to interpret DME orders to look for query opportunities
  • Ability to construct open-ended non-leading written and verbal queries
  • Differentiates between compliant and non-compliant  queries
  • Recognizes opportunities to improve documentation of member’s status of health
  • Recognizes standard medical abbreviations used by medical providers
  • Recognizes query opportunities inherent in members with a history of CHF, COPD, CKD, or Diabetes
  • Ability to communicate with Nurse Practitioners in an effective, non-confrontational manner
  • Recognizes situation in which verbal, personal communication with the Nurse Practitioner is more preferred than written communication
  • Other duties as assigned within the scope of education and license

Core Competencies

  • Maintain current knowledge of the AHIMA practice brief, managing and effective query process
  • Maintain confidentiality of the medical record and other information relevant to the practice of coding and documentation
  • Attentive listening skills
  • Excellent written and verbal communication skills
  • Ability to work independently on clinical note reviews, sitting for lengthy periods of time with a high degree of concentration
  • Risk adjustment / HCC and HEDIS coding knowledge


Experience / Education

  • Basic computer and software skills (e.g. Microsoft Office: Excel / Word, electronic medical record knowledge/use) required
  • Knowledge of federal, state and payer specific regulations, policies and compliance standards pertaining to documentation, coding and billing highly preferred
  • Minimum three years experience in a healthcare setting with practical exposure to health information documentation and coding required
  • Risk Adjustment/HCC and HEDIS coding experience highly preferred

Licensure / Certification

  • Licensed Practical Nurse (LPN) required
  • Registered Health Information Technician highly preferred
  • Registered Health Information Administrator preferred
  • Certified Clinical Documentation Specialist highly preferred
  • Valid Drivers License issued by the Department of Motor Vehicles required

Physical Demands / Working Conditions

  • Must be able to lift up to 20 pounds
  • Must be able to travel daily within Greater New Orleans and Northshore regions as necessary


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