Clinical Documentation Improvement Specialist

South Shore Health System; Weymouth, Northern (MA, KY); Hybrid; USD 103,000 - 154,000; Full time

Job summary

South Shore Health System in Weymouth, MA is seeking a Clinical Documentation Improvement Specialist to perform concurrent reviews of medical records and drive accurate documentation supporting illness severity. This on-site role partners with the Revenue Integrity team to educate physicians and document DRGs for Medicare patients.

The position requires RN licensure in Massachusetts, 5 years of nursing experience with coding education, and CDI experience is preferred. On-site schedule.

Qualifications

• RN licensure in Massachusetts with active practice status.
• BSN preferred.
• 5 years nursing experience with coding education.
• CDI experience preferred.
• Excellent communication and critical thinking skills.

Responsibilities

• Perform concurrent review of admissions to ensure documentation reflects severity of illness.
• Identify diagnoses, procedures, and assign DRG; input into Documentation worksheet.
• Clarify documentation with physicians using appropriate communication methods.
• Input DRG into Epic for Medicare patients and reconcile queries daily.
• Track mortality, queries and case mix for departmental reporting.

Skills

Communication

Critical thinking

Leadership

Education

RN licensure in MA

BSN preferred

Job description

## Clinical Documentation Improvement SpecialistApply: Weymouth, MA: Full time: Posted Yesterday: End Date: November 18, 2026 (30+ days left to apply): R-23770**If you are an existing employee of South Shore Health then please apply through the internal career site.****Requisition Number:**R-23770**Facility:**LOC0001 - 55 Fogg Road55 Fogg RoadWeymouth, 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** **1. Performs concurrent review process for all selected admissions to ensure documentation accurately reflects the severity of patient’s illness**a. 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 b. Identifies and records principle and secondary diagnoses, principle procedures, and assigns a working DRG on Documentation worksheet. c. 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. d. Inputs current DRG into Epic for all Medicare patients daily. e. Inputs and reconciles queries on excel datasheet daily. **2. Provide information and education as necessary to physicians and other care providers specific to DAP.**a. Present overview of program to new physicians and other care providers at orientation b. Follow up with new physicians who document in medical records in a one-to-one meeting c. Provide ongoing information/education as necessary to physicians and other care providers not responding to documentation requests d. Assist in providing feedback to medical staff regarding performance as it relates to accuracy of opportunities to improve documentation. e. Continual medical staff education as a proactive measure. **3. Maintains a collaborative working relationship with team and with the Health Information Management department staff.**a. 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 b. 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 c. Share pertinent coding and DRG reference materials (e.g. coding clinics) d. Share pertinent clinical information (e.g. new drugs/treatments) e. Identification of improvements needed by physicians with continued documentation needs to medical staff liaison for further action **4. Reviews, evaluates, analyzes and interprets data related to documentation from internal sources and external sources on an on-going basis**a. Identifies trends or potential problems and assists in developing action plans to address. **5. Track and provide regular (monthly, other) report for mortality, queries, and case mix in support of hospital wide initiatives.****6. Participates in organizational surveys that evaluate staff perception of safety.****7. Seeks and participates in educational opportunities to improve job skills and program.****8. Demonstrates knowledge of organizational safety priorities and their department specific application, methods of reporting safety concerns and opportunities.****9. Identifies annually at least one implementable idea to improve patient, staff or environmental safety.****10. Successfully answers safety questions in annual mandatory education program.****11. Understands roles/responsibilities during hospital codes.****12. 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 educationClinical Documentation Improvement (CDI) experience preferred.**Required License**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**Responsibilities if Required:****Education if Required:****License/Registration/Certification Requirements:**RN-Registered Nurse - Board of Registration in Nursing (Massachusetts)