RN Clinical Documentation Improvement Specialist

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

Job summary

South Shore Health System in Weymouth, MA is seeking a Clinical Documentation Improvement Specialist to perform concurrent reviews of medical records and drive accurate documentation supporting illness severity. This on-site role partners with the Revenue Integrity team to educate physicians and document DRGs for Medicare patients.

The position requires RN licensure in Massachusetts, 5 years of nursing experience with coding education, and CDI experience is preferred. On-site schedule.

Qualifications

• RN licensure in Massachusetts with active practice status.
• BSN preferred.
• 5 years nursing experience with coding education.
• CDI experience preferred.
• Excellent communication and critical thinking skills.

Responsibilities

• Perform concurrent review of admissions to ensure documentation reflects severity of illness.
• Identify diagnoses, procedures, and assign DRG; input into Documentation worksheet.
• Clarify documentation with physicians using appropriate communication methods.
• Input DRG into Epic for Medicare patients and reconcile queries daily.
• Track mortality, queries and case mix for departmental reporting.

Skills

Communication

Critical thinking

Leadership

Education

RN licensure in MA

BSN preferred

Job description

South Shore Health System in Weymouth, MA is seeking a Clinical Documentation Improvement Specialist to perform concurrent reviews of medical records and drive accurate documentation supporting illness severity. This on-site role partners with the Revenue Integrity team to educate physicians and document DRGs for Medicare patients.

The position requires RN licensure in Massachusetts, 5 years of nursing experience with coding education, and CDI experience is preferred. On-site schedule.