Clinical Documentation & Quality 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

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.