Remote Clinical Documentation Improvement Specialist II

Beth-Israel-Lahey-Health; Burlington (MA); Remote; USD 125,000 - 160,000; Full time

Job summary

Beth Israel Lahey Health is seeking a CDI Specialist II to assist with accurate hospital coding and clinical documentation. This role involves concurrent chart reviews, physician queries, and collaboration with healthcare teams to improve documentation quality and patient outcomes.

The position supports remote work for local candidates in New England, with an emphasis on high-quality documentation and compliance. RN licensure and CDI experience are required or preferred.

Qualifications

• Bachelor's in Nursing required and RN license.
• 2–5 years of medical/surgical experience in acute care.
• CDI certification via ACDIS or AHIMA preferred.

Responsibilities

• Concurrently reviews inpatient records for completeness and accuracy.
• Evaluates documentation for DRG and SOI/ROM considerations.
• Identifies opportunities to query physicians for missing or unclear data.
• Interacts with physicians to obtain documentation when needed.
• Follows query escalation policy and documents follow-up actions.
• Collaborates with CDI team to improve documentation quality.
• Performs mortality reviews and assesses risk of mortality.

Skills

Query writing

Chart audits

Organizational skills

Critical thinking

MS Office

CDI software

Education

Bachelor's in Nursing

Tools

CDI software

Job description

Beth Israel Lahey Health is seeking a CDI Specialist II to assist with accurate hospital coding and clinical documentation. This role involves concurrent chart reviews, physician queries, and collaboration with healthcare teams to improve documentation quality and patient outcomes.

The position supports remote work for local candidates in New England, with an emphasis on high-quality documentation and compliance. RN licensure and CDI experience are required or preferred.