Clinical Documentation Specialist II- RN- Remote

Beth Israel Lahey Health • Burlington, VT

9d • $125,000 - $160,000 • Remote

About The Position

This remote position within the BILH team focuses on improving clinical documentation to accurately reflect patient care. The Clinical Documentation Improvement (CDI) Specialist II assists in identifying diagnoses, conditions, and procedures that represent the patient's hospital stay and care provided, including Severity of Illness (SOI) and Risk of Mortality (ROM). The specialist initiates concurrent queries to providers based on medical record documentation to enhance the accuracy, integrity, and quality of patient data. This role collaborates with coding, clinicians, medical staff, and physician advisors to improve documentation and emphasize its completeness and accuracy within the medical record. Candidates must be local to New England States for consideration.

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

Responsibilities

• 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.
• Identifies 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.

Benefits

• Vaccinated against influenza (flu)

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level