Clinical Documentation Specialist II – RN

🕒 March 4

🦌 Connecticut, Maine, +4 more states – Remote

🦌 Connecticut – Remote 🦞 Maine – Remote 🗻 New Hampshire – Remote 🍂 Massachusetts – Remote ⚓ Rhode Island – Remote 🍁 Vermont – Remote

💵 $102k - $158.4k / year

⏰ Full Time

🟢 Junior

🟡 Mid-level

🏥📝 Medical Writer

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Beth Israel Lahey Health

WebsiteLinkedInAll Job Openings

10,000+ employees

⚕️ Healthcare Insurance

Healthcare Insurance

Beth Israel Lahey Health is a comprehensive healthcare system providing a wide range of medical services and care options to communities in Massachusetts and New Hampshire. With a network of 14 hospitals, including community hospitals and specialized centers for orthopedic and behavioral health care, they offer personalized care for all health needs. Their services include emergency care, primary care, urgent care, pharmacy services, home care, and more. Dedicated to improving community health and well-being, Beth Israel Lahey Health is committed to research, education, and providing extraordinary care through its 39,000 team members.

📋 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.

🎯 Requirements

• Bachelor’s in Nursing, required • RN License • Clinical Documentation Specialist Certification via ACDIS or AHIMA • 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 role • Critical Care and/or Emergency Nursing experience required • 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

🏖️ Benefits

• Comprehensive compensation and benefits • Support for achieving a healthy and balanced life