Clinical Documentation Improvement Specialist

Beth Israel Lahey Health; Boston (MA); On-site; USD 102,000 - 158,392; Full time

Job summary

A leading healthcare provider in Boston is seeking a Clinical Documentation Improvement (CDI) Specialist II to enhance the accuracy and quality of patient documentation. Responsibilities include reviewing inpatient records, collaborating with physicians for documentation improvement, and ensuring compliance with documentation guidelines. The ideal candidate must have a Bachelor’s in Nursing, an RN license, and 2-5 years of medical/surgical nursing experience. The position offers a competitive salary range of $102,000 to $158,392 USD.

Qualifications

• RN License is required.
• Clinical Documentation Specialist Certification via ACDIS or AHIMA is necessary.
• 2-5 years of medical/surgical nursing experience in acute hospital settings.

Responsibilities

• Review inpatient records for completeness and accuracy.
• Evaluate documentation for DRG assignment.
• Identify documentation improvement opportunities.
• Interact with physicians to obtain additional documentation.
• Facilitate modifications to documentation for complexity of care.

Skills

Query writing to physicians

Chart audits

Organizational skills

Critical thinking

Microsoft Office applications

Education

Bachelor’s in Nursing

Job description

Job Description

The Clinical Documentation Improvement (CDI) Specialist II assists with the appropriate identification of diagnoses, conditions, and/or procedures that are representative of the patient’s hospital stay and care provided, including Severity of Illness (SOI) and Risk of Mortality (ROM) during an inpatient hospitalization. The CDI Specialist II initiates concurrent queries to providers as supported by medical record documentation to improve the accuracy, integrity, and quality of patient data, and to drive improvement toward quality physician documentation within the medical record. The CDI Specialist II works under the direction of the Manager of CDI and collaborates with coding, clinicians, medical staff, and physician advisors to improve documentation and the importance of complete and accurate documentation.

Essential Duties & Responsibilities

• Concurrently reviews inpatient records to ensure completeness, accuracy, and clinical validation.
• Evaluates documentation for assignment of working and possible DRG.
• Recognizes opportunities for documentation improvement, including severity of illness, risk of mortality, core measures, and patient safety/quality.
• Identifies opportunities to query physicians regarding missing, unclear, or conflicting documentation.
• Interacts directly with physicians to request and obtain additional documentation when needed.
• Timely follow-up on all unanswered queries based on the query escalation policy.
• Facilitates modifications to physician documentation to reflect the complexity of care of the patient and appropriate reimbursement.
• Maintains a collaborative working relationship with the Health Information Coding staff and serves as a clinical resource.
• Collaborates with and educates members of the patient care team regarding documentation guidelines, including physicians, allied health practitioners, nursing, and case management.
• Performs mortality reviews and optimizes the risk of mortality.
• Maintains review worksheet on all records using CDI software.
• Ensures the accuracy of clinical information used for measuring and reporting physician and hospital quality outcomes.
• Reviews, evaluates, analyzes, and interprets data related to documentation on an ongoing basis. Identifies trends or potential problems and assists in developing action plans to address them.
• Participates in additional projects such as developing physician education materials, CDI week advertisements, etc.
• Adheres to ethical and professional business practices.
• All other duties as assigned.
• It is understood that this is a summary of key job functions and does not include every detail of the job that may reasonably be required.

Education

Bachelor’s in Nursing, required.

Licensure, Certification & Registration

• RN License
• Clinical Documentation Specialist Certification via ACDIS or AHIMA

Experience

• 2-5 years of medical/surgical nursing experience in the acute hospital setting.
• Critical Care and/or Emergency Nursing experience required.

Skills, Knowledge & Abilities

• Proficient skill in query writing to physicians.
• Knowledge to accurately complete chart audits.
• Organizational and critical thinking skills required.
• Experience with computer systems, including web-based applications and Microsoft Office applications (Outlook, Word, Excel, PowerPoint, or Access).

Pay Range

$102,000.00 USD - $158,392.00 USD.

EEO Statement

Equal Opportunity Employer/Veterans/Disabled.

Vaccination Policy

All staff must be vaccinated against influenza as a condition of employment.