Clinical Documentation Specialist III – RN

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 III 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 III 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 III 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:

• Concurrently reviews inpatient records to ensure completeness, accuracy, and clinical validation.

• Evaluates documentation for assignment of working and possible DRG.

• Serves as a database manager for CDI tracking tool, including DRG validation for accurate and timely reporting of CDI-generated reimbursement and case mix index improvement. Manages data not obtainable by canned reports.

• Recognizes opportunities for documentation improvement, including severity of illness, risk of mortality, core measures, and patient safety/quality.

• Identify opportunities to query physicians regarding missing, unclear, or conflicting documentation.

• Interacts directly with physicians to request and obtain additional documentation when needed.

• Timely follow-up on all unanswered queries based on the query escalation policy.

• Facilitates modifications to physician documentation to reflect the complexity of care of the patient and appropriate reimbursement.

• Maintains a collaborative working relationship with the Health Information Coding staff and serves as a clinical resource.

• Collaborates with and educates members of the patient care team regarding documentation guidelines, including physicians, allied health practitioners, nursing, and case management.

• Performs mortality reviews and optimizes the risk of mortality.

• Maintains review worksheet on all records using CDI software.

• Ensures the accuracy of clinical information used for measuring and reporting physician and hospital quality outcomes.

• Reviews, evaluates, analyzes, and interprets data related to documentation on an ongoing basis. Identifies trends or potential problems and assists in developing action plans to address.

• Participates in additional projects such as developing physician education materials, CDI week advertisements, etc.

• Serves as a liaison between the CDI department and physicians.

• Participates in CDI department and senior leadership meetings as a subject matter expert.

• Adheres to ethical and professional business practices.

• All other duties as assigned.

• It is understood that this is a summary of key job functions and does not include every detail of the job that may reasonably be required.

Minimum Qualifications:

Education:

Bachelor’s in Nursing, required

Licensure, Certification & Registration:

• RN License

• Clinical Documentation Specialist Certification via ACDIS or AHIMA

Experience:

• 5 years of medical/surgical nursing experience in the acute hospital setting.

• Critical Care and/or Emergency Nursing experience required

Skills, Knowledge & Abilities:

• Proficient skill in query writing to physicians

• Knowledge to accurately complete chart audits

• Organizational and critical thinking skills required

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

Pay Range:

$144,000.00 USD – $176,000.00 USD

The pay range listed for this position is the annual base salary range the organization reasonably and in good faith expects to pay for this position at this time. Actual compensation is determined based on several factors, that may include seniority, education, training, relevant experience, relevant certifications, geography of work location, job responsibilities, or other applicable factors permissible by law. 

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

Salary : $144,000 - $176,000