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Job Description:

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

Evaluates documentation for assignment of working and possible DRG.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.

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 LicenseClinical Documentation Specialist Certification via

ACDIS or AHIMAExperience:

2-5 years of medical/surgical nursing experience in the acute hospital setting.

Experienced Clinical Documentation Specialist with minimum of 2 years recent experience in CDI roleCritical Care and/or Emergency Nursing experience required

Skills, Knowledge & Abilities:

Proficient skill in query writing to physiciansKnowledge to accurately complete chart auditsOrganizational and critical thinking skills requiredExperience with computer systems required, including web-based applications and some Microsoft Office applications which may include

Outlook, Word, Excel, PowerPoint, or Access Pay Range:

$125,000.00 USD - $160,000.00 USDThe 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.

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Find & Apply For Document Control / Management Specialist Jobs in Burlington, Massachusetts

Clinical Documentation Specialist II- RN- Remote