Sr Clinical Doc Spclst

LCS Lifespan Corporate Services d/b/a Brown University Health; United States; On-site; USD 94,000 - 188,000; Full time

Job summary

Brown University Health seeks a Senior Clinical Documentation Specialist to audit and improve clinical documentation quality, ensuring accurate severity, risk of mortality, and complexity of care. You will collaborate with physicians, nursing staff, and coding to maximize specificity and educational impact.

You will use advanced CDI methods with tools like EPIC, 3M/360 Life Chart, and query development to educate staff, manage workflow, and support outcomes reporting.

Qualifications

• 3 years of clinical documentation experience in acute care.
• BSN required; master's degree preferred.
• Active RN license in Rhode Island or equivalent licensure.
• ACDIS or AHIMA certification is a plus.
• Experience with ICD-10 and MS-DRG coding and queries.

Responsibilities

• Demonstrates expert knowledge of CDI issues related to ICD-10 and DRG assignment.
• Educates and mentors staff; develops educational materials for providers.
• Performs concurrent and retrospective reviews using risk-adjusted methods.
• Develops and updates CDI query templates and tests platforms (EPIC, 3M/360).
• Manages EPIC work queues and develops complex queries with staff guidance.
• Performs standard CDI reviews meeting productivity, 20–24 reviews/day.

Skills

Clinical documentation

ICD-10 coding

MS-DRG

EPIC

3M/360 Life Chart

Query development

Mentoring

Productivity management

Education

RN with Rhode Island licensure

BSN

Master's degree preferred

Physician assistant or nurse practitioner license

ACDIS/AHIMA certification

Tools

EPIC

3M/360 Life Chart

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

Company Description

As Rhode Island's largest health system and private employer, Brown University Health is the state's premier provider of health services and includes the only Level I Trauma Center for southeastern New England. Today, more than 20,000 people work at Brown University Health and bring their unique skills, experiences, and compassion to their jobs every day. Formed in 1994, Brown University Health is a not-for-profit health system based in Providence, RI comprising three teaching hospitals of The Warren Alpert Medical School of Brown University: Rhode Island Hospital and its Hasbro Children's; The Miriam Hospital; and Bradley Hospital, the nation’s first psychiatric hospital for children; Newport Hospital, Saint Anne's Hospital and Morton Hospital, community hospitals offering a broad range of health services; Gateway Healthcare, the state’s largest provider of community behavioral health care; and Brown Health Medical Group, the largest multi-specialty practice in Rhode Island. Brown University Health is an equal opportunity employer that values diversity of cultural background, race, gender, age, religion, identity, ability, and perspectives - we are actively committed to a diverse workforce that represents the patients and community that we serve. We are invested in creating a respectful, inclusive, and equitable environment that supports the holistic well-being of our employees and their families. Join us and help build a healthier future for our patients - and for yourself.