Clinical Documentation Specialist

When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives.

The Clinical Documentation Improvement (CDI) Specialist Registered Nurse (RN) assists with the appropriate identification of diagnoses, conditions, and/or procedures that are representative of the patient’s hospital stay and care provided including Severity of Illness (SOI), Risk of Morality (ROM), during an inpatient hospitalization. CDI Specialist RN initiates concurrent queries to providers as supported by medical record documentation to improve the accuracy, integrity, and quality of patient data, and drive improvement toward quality physician documentation within the body of the medical record. The CDI Specialist RN works under the direction of the Manager of CDI and collaborates with coding, clinicians, medical staff, and physician advisors to improve documentation and the importance of complete and accurate documentation.

Job Description:

Essential Duties & Responsibilities including but not limited to:

Completes initial reviews of patient records within 24-48 hours of admission

Evaluate documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate DRG assignment, risk of morality, and severity of illness.

Track review details in 3M software.

Conducts follow-up reviews of patients every 2 days to support and assign a working DRG assignment. Queries physicians regarding missing, unclear, or conflicting medical record documentation by requesting and obtaining additional documentation within the medical record when needed. Educates physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the medical record. Collaborates with the CDI Manager & Physician Advisor and other ancillary staff regarding interaction with physicians on documentation and to resolve physician queries prior to patient discharge. Educates members of the patient care team regarding documentation opportunities and best practices to ensure accurate documentation in the medical record. Applies diplomacy and professionalism when interacting with physicians and clinicians; especially when addressing missing or conflicting medical record information. Works in partnership with an interdisciplinary team to foster collaboration, learning, and accurate and complete medical record documentation. Exhibits working knowledge of inpatient coding guidelines. Adheres to CDI convention and department policies and procedures. Investigates, evaluates, and identifies opportunities for improvement and recognizes their relative significance in the overall system. Provides orientation for new clinical staff regarding documentation requirements as required. Keeps current with CDI concepts and practices through conferences, reference material, and review of current literature. Maintains confidentiality of all customer/hospital information. Demonstrates flexibility in the face of a changing work environment, adjusting work schedule accordingly.

Minimum Qualifications:

Education:

• Associate’s degree required. Bachelor's degree preferred.
• Licensure, Certification & Registration:
• RN license required

Experience:

• 3-5 years of related work experience required in a clinical nursing practice, which includes medical, surgical, and/or ICU background.

Skills, Knowledge & Abilities:

• Experience with computer systems required, including web-based applications and some Microsoft Office applications which may include Outlook, Word, Excel, PowerPoint, or Access

Preferred Qualifications & Skills:

• BS in Nursing with 5-8 years of acute care clinical experience.
• Certified Clinical Documentation Specialist (CCDS) or Certified Clinical Documentation Improvement Professional (CDIP)
• Experience with DRG Reimbursement and ICD-10 Coding

As a health care organization, we have a responsibility to do everything in our power to care for and protect our patients, our colleagues and our communities. Beth Israel Lahey Health requires that all staff be vaccinated against influenza (flu) as a condition of employment.

More than 35,000 people working together. Nurses, doctors, technicians, therapists, researchers, teachers and more, making a difference in patients' lives. Your skill and compassion can make us even stronger.

Equal Opportunity Employer/Veterans/Disabled