RN CDI Specialist: Clinical Documentation Improvement

South Shore Health; Weymouth (MA); On-site; USD 103,000 - 154,000; Full time

Job summary

South Shore Health seeks a Documentation Specialist to support the CDI program, reviewing medical records to ensure accurate severity of illness and appropriate DRG coding. On-site role with a focus on concurrent reviews and physician communication to improve documentation quality.

The position requires nursing licensure in Massachusetts, 5+ years of nursing experience with coding knowledge, and a strong aptitude for education and collaboration with medical staff.

Qualifications

• Graduate from accredited nursing program with active MA license.
• Five years nursing experience with coding education.
• CCS certification preferred.
• RN licensure required in Massachusetts.
• Excellent communication and critical thinking skills.

Responsibilities

• Perform concurrent review of admissions to ensure documentation reflects illness severity.
• Produce daily Epic worklists and review patient stay to support timely coding.
• Identify and record principal/secondary diagnoses and DRG assignments.
• Clarify documentation with physicians using appropriate communication methods.
• Input DRG into Epic and reconcile queries daily (Excel/yield).
• Provide education to physicians on documentation accuracy and DAP.
• Present program overview to new physicians during orientation.
• Follow up with physicians for documentation improvements and responsiveness.

Skills

Excellent communication skills

Leadership abilities

Critical thinking

Time management

Education

RN license in Massachusetts

BSN preferred

Job description

South Shore Health seeks a Documentation Specialist to support the CDI program, reviewing medical records to ensure accurate severity of illness and appropriate DRG coding. On-site role with a focus on concurrent reviews and physician communication to improve documentation quality.

The position requires nursing licensure in Massachusetts, 5+ years of nursing experience with coding knowledge, and a strong aptitude for education and collaboration with medical staff.