Clinical Documentation Improvement Specialist

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

Job Type

Regular

Scheduled Hours

36

Work Shift

Day (United States of America)

RN CLINICAL DOCUMENTATION SPECIALIST

Job Description

General Statement of Duties

Provides concurrent review of the clinical documentation in the medical record; review the medical record with a clinical lens to identify any missing or understated diagnoses. Key responsibility will be to review the chart for information not currently in the chart but that is indicated by clinical indicators in the record. Queries the medical staff when necessary by written and/or verbal communication to obtain accurate and complete physician documentation that supports the patient condition(s) and treatment plan. Performs a thorough chart review to determine the appropriate principal diagnosis of the patient. Demonstrates an understanding of the importance of, and makes an effort to capture, all appropriate secondary diagnoses for quality rating purposes. Coordinates with coding/HIM/UR and other departments to achieve a record that reflects the acuity of the patient and level of care provided. Demonstrates creativity and enthusiasm while pursuing the goals of the department and the organization. Maintains flexibility and prioritizes daily responsibilities.

Typical Responsibilities and Allocation of Time

60%: Conducts initial and follow-up concurrent reviews on inpatient admissions for opportunities to clarify documentation in the medical record for accurate reflection of the acuity of the patient and justifying the level of care. Documents findings in workflow tools, noting all key information used in the tracking process. Review medical record concurrently for documentation not yet in the record but supported by clinical indicators. 25%: Uses relationship building and strong communication skills to develop a rapport with providers to clarify information in the medical record. Uses appropriate querying templates to get needed documentation. Conducts follow-up on unanswered queries during the patient stay to obtain a response to unanswered queries. 10%: Provides education to physicians on the importance of complete documentation and key documentation concepts during regular physician meetings or on individually with physicians. 5%: Use data provided by managers, directors, and consulting team to actions to identify what is working well and areas of focus

Required Knowledge, Skills, and Working Conditions

Extensive clinical knowledge and understanding of pathology/physiology; best demonstrated by clinical experience in hospital setting. Strong critical thinking skills and the ability to review the medical record to identify information not yet documented but supported by clinical indicators or clinical clues. Knowledge of age-specific patient needs and the elements of disease processes and related procedures. Excellent written and verbal communication skills; ability to write concisely and effectively when communicating with providers. Assertive personality traits to facilitate ongoing physician communication Working knowledge of inpatient admission criteria. Ability to work independently in a time-oriented environment. Ability to stand and walk in the performance of job responsibilities.

Acceptable Experience Backgrounds

RN license Bachelor's degree in Nursing Minimum of 5 years of clinical experience in an acute care setting. Backgrounds include: Inpatient bedside nursing Case management Open to people with previous CDI experience, but not at all required

FLSA Status

Exempt

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) and COVID-19 as a condition of employment. Learn more about this requirement.

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Equal Opportunity Employer/Veterans/Disabled