Nursing CDI Specialist: Clinical Documentation & Revenue

southshorehealth; Weymouth (MA); On-site; USD 103,000 - 154,000; Full time

Job summary

Southshore Health in Weymouth, MA is seeking a Documentation Specialist to support the hospital's CDI program. Under the general supervision of the Manager of Clinical Documentation, you will assist to develop, implement, and maintain the documentation accuracy initiative at the Hospital.

This role is on-site and available five days a week. Key duties include concurrent review of medical records to ensure accurate documentation of illness severity, physician query to obtain clarity, and input of

Qualifications

• Graduate from an accredited school of nursing with MA license.
• RN license in Massachusetts may be required.
• CDI experience preferred and coding education background.
• BSN preferred; CCS certification preferred.

Responsibilities

• Perform concurrent review to ensure documentation reflects illness severity.
• Query physicians for accurate documentation using appropriate methods.
• Input DRG into Epic for Medicare patients daily.
• Input and reconcile queries on an Excel datasheet daily.
• Provide information and education to physicians on DAP.
• Maintain collaborative relationships with HIM and team.
• Track monthly mortality, queries, and case mix for initiatives.

Skills

Leadership

Communication

Critical thinking

Team collaboration

Education

BSN preferred

RN license

CCS certification

Tools

Epic

Job description

Southshore Health in Weymouth, MA is seeking a Documentation Specialist to support the hospital's CDI program. Under the general supervision of the Manager of Clinical Documentation, you will assist to develop, implement, and maintain the documentation accuracy initiative at the Hospital.

This role is on-site and available five days a week. Key duties include concurrent review of medical records to ensure accurate documentation of illness severity, physician query to obtain clarity, and input of