Senior Clinical Documentation Specialist & Educator

Brown Medicine; United States; On-site; USD 94,000 - 188,000; Full time

Job summary

Brown University Health is seeking a Senior Clinical Documentation Specialist to oversee concurrent auditing and coding quality, ensuring the severity of illness and risk of mortality are accurately reflected. You will collaborate with physicians, nursing staff and coding to improve documentation and accuracy.

The role requires Rhode Island RN licensure (or PA/NP) with CDI experience, certification in CDI, and experience with 3M/360 and EPIC.

Qualifications

• RN in Rhode Island with 3 years of clinical documentation experience (BSN required; master's preferred).
• Physician assistant or nurse practitioner with current licensure in Rhode Island and 3 years CDI experience, or equivalent medical degree with 3 years CDI experience.
• ACDIS or AHIMA CDI certification required.

Responsibilities

• Demonstrates expert knowledge of clinical documentation issues related to proper assignment of ICD-10 codes and DRG assignment.
• Performs concurrent and retrospective reviews using risk-adjusted methodology for Mortality and HAC/PSI reviews.
• Assists with developing, reviewing, and updating of query templates.
• Assists with precepting and education of new staff and mentoring of less experienced staff.
• Able to develop more complex queries and assist staff in this area.

Education

BSN required

Master’s degree preferred

Tools

3M/360

Life Chart

EPIC

Job description

Brown University Health is seeking a Senior Clinical Documentation Specialist to oversee concurrent auditing and coding quality, ensuring the severity of illness and risk of mortality are accurately reflected. You will collaborate with physicians, nursing staff and coding to improve documentation and accuracy.

The role requires Rhode Island RN licensure (or PA/NP) with CDI experience, certification in CDI, and experience with 3M/360 and EPIC.