Sr Clinical Doc Spclst

Lifespan; Providence (RI); On-site; USD 94,000 - 188,000; Full time

Job summary

Brown University Health is seeking a Senior Clinical Documentation Specialist to lead concurrent documentation audits and collaborate with care teams to reflect illness severity and complexity. You will work with physicians, nurses, and coders to ensure precise ICD-10 coding and DRG assignment, while educating staff on documentation improvements.

The role emphasizes CDI expertise, Epic system proficiency, and ongoing education to support hospital outcomes and compliance.

Qualifications

• RN licensure in Rhode Island with 3 years of clinical documentation experience
• ACDIS or AHIMA certification required
• BSN required; master's preferred; or PA/NP/MD with CDI experience

Responsibilities

• Conduct concurrent and retrospective reviews using risk-adjusted methods for Mortality and HAC/PSI.
• Develop educational materials and mentor staff to improve documentation specificity.
• Collaborate with physicians, nursing staff, and coding to ensure accurate ICD-10 and DRG assignments.
• Manage EPIC work queues and test platforms; develop complex queries for CDI.
• Maintain productivity targets (20–24 reviews per day) and perform follow-ups on CDI queries.

Skills

Clinical documentation experience

ACDIS/AHIMA certification

3M/360 Life Chart

EPIC systems

Education

RN licensure in Rhode Island

BSN required

Master's degree preferred

PA/NP or MD licensure with CDI experience

Tools

3M/360

Life Chart

EPIC Work Queue

Job description

SUMMARY

The Senior Clinical Documentation Specialist will directly report to the Manager of Clinical Documentation. Under general supervision and within Brown University Health policies and procedures, is responsible for concurrent auditing of medical record documentation to assist with evaluating and improving the quality of clinical documentation of services to adequately reflect severity of illness, expected risk of mortality, and complexity of care of the patient. Communicates and collaborates with physicians, mid-level providers, nursing staff, other patient caregivers to improve quality and completeness of documentation. Communicates and collaborates with the coding staff to ensure patient documentation is coded to the highest specificity. Facilitates concurrent modifications to clinical documentation to ensure clinical severity and services rendered to patients are documented accurately. Supports timely, accurate and complete documentation of clinical information used for measuring and reporting physician and facility outcomes. Updates and educates all members of patient care team on ongoing basis in regard to documentation issues.

Brown University Health employees are expected to successfully role model the organization's values of Compassion, Accountability, Respect, and Excellence as these values guide our everyday actions with patients, customers and one another.

RESPONSIBILITIES

• Demonstrates expert knowledge of clinical documentation issues as they relate to proper assignment of ICD 10 codes and MS-DRGPR DRG assignment.
• Assists with the precepting and education of new staff and mentoring of less experienced staff.
• Identifies and develops educational materials for providers to assist the medical staff in improving the specificity of their documentation independently and as directed.
• Accurately performs concurrent and retrospective reviews utilizing risk adjusted methodology per departmental policy for Mortality and HAC/PSI reviews.
• Assists with specific individual or departmental audits provides a report outlining opportunities as well as the strengths as directed.
• Assists with developing, reviewing, and updating of query templates.
• Demonstrates advanced technical ability with 3M/360, Life Chart as well as other online programs.
• Able to test technical platforms as needed.
• Assists with EPIC Work queue management: i.e., WQ 21480 Retrospective Reviews.
• Able to develop more complex queries as well as assists and develops staff in this area.
• Performs Follow ups on Coding RETRO Queries as necessary Performs duties of Clinical Documentation Specialist.
• Ability to perform standard CDI reviews according to productivity expectations of this role. Productivity standards in this role are 20 - 24 reviews per day which include the review of more complex cases. Performs other duties as assigned.

MINIMUM QUALIFICATIONS

• Licensure as Registered Nurse in the State of Rhode Island by the Rhode Island Board of Nursing or licensure as a Registered Nurse in accordance with the Nurse Licensure Compact agreement of the National Council of State Boards of Nursing.

QUALIFICATIONS

• Registered nurse with current licensure to practice in the State of Rhode Island with 3 years of clinical documentation experience (BSN required, master's degree preferred), or Physician assistant or nurse practitioner with current licensure to practice in the State of Rhode Island with 3 years of clinical documentation experience, or Successful completion of education required for a medical degree with 3 years of clinical documentation experience
• Certification in clinical documentation integrity from the Association of Clinical Documentation Integrity Specialists (ACDIS) or the strong American Health Information Management Association (/strongAHIMA) required.

Pay Range

$93,974.40-$187,907.20

EEO Statement

Brown University Health is committed to providing equal employment opportunities and maintaining a work environment free from all forms of unlawful discrimination and harassment.

Location

Corporate Headquarters - 15 LaSalle Square Providence, Rhode Island 02903

Work Type

M-F 8:00am-5:00pm

Work Shift

Day

Daily Hours

8 hours

Driving Required

No