Clinical Documentation Improvement Specialist

South Shore Health; Weymouth (MA); On-site; USD 103,000 - 154,000; Full time

Job summary

South Shore Health seeks a Documentation Specialist to support the CDI program, reviewing medical records to ensure accurate severity of illness and appropriate DRG coding. On-site role with a focus on concurrent reviews and physician communication to improve documentation quality.

The position requires nursing licensure in Massachusetts, 5+ years of nursing experience with coding knowledge, and a strong aptitude for education and collaboration with medical staff.

Qualifications

• Graduate from accredited nursing program with active MA license.
• Five years nursing experience with coding education.
• CCS certification preferred.
• RN licensure required in Massachusetts.
• Excellent communication and critical thinking skills.

Responsibilities

• Perform concurrent review of admissions to ensure documentation reflects illness severity.
• Produce daily Epic worklists and review patient stay to support timely coding.
• Identify and record principal/secondary diagnoses and DRG assignments.
• Clarify documentation with physicians using appropriate communication methods.
• Input DRG into Epic and reconcile queries daily (Excel/yield).
• Provide education to physicians on documentation accuracy and DAP.
• Present program overview to new physicians during orientation.
• Follow up with physicians for documentation improvements and responsiveness.

Skills

Excellent communication skills

Leadership abilities

Critical thinking

Time management

Education

RN license in Massachusetts

BSN preferred

Job description

Job Requirements

Requisition Number
R-23770

Facility
LOC0001 - 55 Fogg Road55 Fogg Road Weymouth, MA 02190

Department Name
SHS Revenue Integrity

Status
Full time

Budgeted Hours
40

Shift
Day (United States of America)

Under the general supervision of the Manager of Clinical Documentation, will assist to develop, implement, and maintain the documentation accuracy initiative at the Hospital. This position is responsible for the concurrent review of the clinical documentation in the medical record and concurrent querying of medical staff caregivers to obtain accurate and complete documentation, which appropriately supports the severity of patient illness. The documentation specialist is on-site and available five (5) days a week.

Compensation Pay Range
$103,000.00 - $153,700.00

Essential Functions

• Performs concurrent review process for all selected admissions to ensure documentation accurately reflects the severity of patient’s illness
• Produce worklists from Epic daily to review case on day 2 as well as daily throughout the patient’s stay. Patients admitted and discharged on the weekend will be reviewed in coding before the bill is dropped. Review all inpatient cases and observation or surgical day cases that has the potential to be converted to an inpatient admission
• Identifies and records principle and secondary diagnoses, principle procedures, and assigns a working DRG on Documentation worksheet.
• Identifies need to clarify documentation in records and initiates assertive communication with physician or other care provider by using the most appropriate communication method for that individual - physician documentation request, face to face contact, phone call, etc.
• Inputs current DRG into Epic for all Medicare patients daily.
• Inputs and reconciles queries on excel datasheet daily.
• Provide information and education as necessary to physicians and other care providers specific to DAP.
• Present overview of program to new physicians and other care providers at orientation
• Follow up with new physicians who document in medical records in a one-to-one meeting
• Provide ongoing information/education as necessary to physicians and other care providers not responding to documentation requests
• Assist in providing feedback to medical staff regarding performance as it relates to accuracy of opportunities to improve documentation.
• Continual medical staff education as a proactive measure.
• Maintains a collaborative working relationship with team and with the Health Information Management department staff.
• Perform focused reviews, both concurrently and retrospectively, to determine areas where information and/or education may be required for the team or members of the team to improve program effectiveness
• Perform focused reviews, both concurrently and retrospectively, to determine areas where information and/or education may be required for physicians or other care providers to improve program effectiveness
• Share pertinent coding and DRG reference materials (e.g. coding clinics)
• Share pertinent clinical information (e.g. new drugs/treatments)
• Identification of improvements needed by physicians with continued documentation needs to medical staff liaison for further action
• Reviews, evaluates, analyzes and interprets data related to documentation from internal sources and external sources on an on-going basis
• Identifies trends or potential problems and assists in developing action plans to address.
• Track and provide regular (monthly, other) report for mortality, queries, and case mix in support of hospital wide initiatives.
• Participates in organizational surveys that evaluate staff perception of safety.
• Seeks and participates in educational opportunities to improve job skills and program.
• Demonstrates knowledge of organizational safety priorities and their department specific application, methods of reporting safety concerns and opportunities.
• Identifies annually at least one implementable idea to improve patient, staff or environmental safety.
• Successfully answers safety questions in annual mandatory education program.
• Understands roles/responsibilities during hospital codes.
• Adheres to respiratory etiquette guidelines.

Job Requirements

Minimum Education
Graduate from an accredited school of nursing with a license to practice professional nursing in Massachusetts

BSN preferred

Minimum Work Experience
Five (5) years nursing experience with coding education

Required License
Clinical Documentation Improvement (CDI) experience preferred.

RN - Registered Nurse

Preferred Certification
CCS - Certified Coding Specialist

Required Additional Knowledge, And Abilities

Excellent communication and critical thinking skills.

Demonstrates leadership qualities such as the ability to motivate, teach, and facilitate individuals and groups on reaching the objectives of the program.

Working knowledge of Medicare and Blue Cross inpatient reimbursement and coding structures is desired.

Knowledge of care delivery documentation systems and related medical record documents desired.

Knowledge of age-specific needs and the elements of disease processes and related procedures preferred.

Self-motivated, innovative individual who has the ability to work in a time-oriented environment.

Prefer experience interacting with physicians and concurrent review with clinical records.

Basic Personal Computer Skills Required.

Day shift 8:00 am to 4:30 pm

License/Registration/Certification Requirements

RN-Registered Nurse - Board of Registration in Nursing (Massachusetts)