Clinical Documentation Improvement Specialist-RN- Remote

Beth Israel Lahey Health; Boston (MA); Remote; USD 70,000 - 90,000; Full time

Job summary

A health care organization is seeking a Clinical Documentation Improvement Specialist (RN) to enhance the accuracy and quality of patient documentation. The ideal candidate will have experience in clinical nursing and a strong ability to work with interdisciplinary teams. Responsibilities include reviewing patient records, providing guidance to clinicians, and ensuring adherence to documentation standards. This position requires a flexible approach in a changing environment with a focus on improvement.

Qualifications

• Registered Nurse (RN) license required.
• 3-5 years of related clinical nursing practice.
• Experience with computer systems, including web-based applications.

Responsibilities

• Completes reviews of patient records within 24-48 hours of admission.
• Tracks review details in coding software.
• Collaborates with healthcare providers to improve documentation.

Skills

Clinical documentation improvement

Communication skills

Flexibility

Interdisciplinary collaboration

Education

Associate’s degree

Bachelor's degree

Tools

3M software

Microsoft Office

Job description

Clinical Documentation Improvement Specialist-RN- Remote

The Clinical Documentation Improvement (CDI) Specialist Registered Nurse (RN) assists with the identification of diagnoses, conditions, and procedures that are representative of the patient’s hospital stay and care. The CDI Specialist RN initiates concurrent queries to providers to improve the accuracy, integrity, and quality of patient data and to drive improvement in physician documentation within the medical record. The CDI Specialist RN works under the direction of the Manager of CDI and collaborates with coding, clinicians, medical staff, and physician advisors to improve documentation and ensure complete and accurate documentation.

Essential Duties & Responsibilities

• Completes initial reviews of patient records within 24-48 hours of admission.
• Evaluates documentation to assign principal and secondary diagnoses and procedures for accurate DRG assignment, risk of mortality, and severity of illness.
• Tracks review details in 3M software.
• Conducts follow-up reviews of patients every 2 days to support and assign a working DRG; queries physicians regarding missing, unclear, or conflicting documentation and requests additional documentation as needed.
• Educates physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate documentation in the medical record.
• Collaborates with the CDI Manager, Physician Advisor, and other staff to resolve physician queries prior to patient discharge.
• Educates members of the patient care team regarding documentation opportunities and best practices to ensure accurate documentation in the medical record.
• Maintains professionalism when interacting with physicians and clinicians, addressing missing or conflicting information diplomatically.
• Works with an interdisciplinary team to foster collaboration and accurate medical record documentation.
• Demonstrates knowledge of inpatient coding guidelines and adheres to CDI conventions and department policies.
• Investigates, evaluates, and identifies opportunities for improvement and communicates their significance within the system.
• Provides orientation for new clinical staff regarding documentation requirements as required.
• Keeps current with CDI concepts and practices through conferences, references, and current literature.
• Maintains confidentiality of all hospital information.
• Demonstrates flexibility in a changing work environment and adjusts work schedule accordingly.

Minimum Qualifications

• Education: Associate’s degree required; Bachelor's degree preferred.
• Licensure, Certification & Registration: RN license required.
• Experience: 3-5 years of related clinical nursing practice (medical, surgical, and/or ICU).
• Skills, Knowledge & Abilities: Experience with computer systems, including web-based applications and Microsoft Office (Outlook, Word, Excel, PowerPoint, or Access).

Preferred Qualifications & Skills

• BS in Nursing with 5-8 years of acute care clinical experience.
• Certified Clinical Documentation Specialist (CCDS) or Certified Clinical Documentation Improvement Professional (CDIP).
• Experience with DRG reimbursement and ICD-10 coding.

Equal Opportunity Employer/Veterans/Disabled

As a health care organization, we require that all staff be vaccinated against influenza as a condition of employment.