Sr Clinical Doc Spclst
About The Position
The Senior Clinical Documentation Specialist reports directly to the Manager of Clinical Documentation. Under general supervision and in accordance with Brown University Health policies and procedures, this role conducts concurrent auditing of medical record documentation to help evaluate and improve documentation quality. The goal is to ensure records accurately reflect patient severity of illness, expected risk of mortality, and complexity of care. The specialist collaborates with physicians, mid-level providers, nursing staff, other caregivers, and coding staff to improve documentation quality, completeness, and coding specificity. The role facilitates concurrent documentation modifications and supports timely, accurate, and complete clinical information used to measure and report physician and facility outcomes. It also provides ongoing education to members of the patient care team on documentation issues. The position requires expert clinical documentation knowledge and advanced technical capability, including experience with 3M/360, Life Chart, and other online programs. It includes complex and standard CDI reviews, retrospective and concurrent audits, query development, technical platform testing, EPIC work queue management, follow-up on coding retrospective queries, and support for staff education and development. The stated productivity expectation is 20–24 reviews per day, including more complex cases. Brown University Health employees are expected to model the organization's values of Compassion, Accountability, Respect, and Excellence.
Requirements
- Current Registered Nurse licensure in Rhode Island through the Rhode Island Board of Nursing or licensure in accordance with the Nurse Licensure Compact agreement of the National Council of State Boards of Nursing; alternatively, the qualifications specify a physician assistant, nurse practitioner, or medical degree pathway with current Rhode Island licensure where applicable.
- Three years of clinical documentation experience.
- For the registered nurse pathway, a BSN is required.
- Certification in clinical documentation integrity from the Association of Clinical Documentation Integrity Specialists (ACDIS) or the American Health Information Management Association (AHIMA) is required.
Nice To Haves
- Master's degree preferred.
Responsibilities
- Demonstrate expert knowledge of clinical documentation issues as they relate to proper assignment of ICD-10 codes and MS-DRGPR DRG assignment.
- Assist with precepting and educating new staff and mentoring less experienced staff.
- Identify and develop educational materials, independently and as directed, to help providers improve documentation specificity.
- Accurately perform concurrent and retrospective reviews using risk-adjusted methodology for Mortality and HAC/PSI reviews, in accordance with departmental policy.
- Assist with individual or departmental audits and provide reports outlining opportunities and strengths as directed.
- Assist with developing, reviewing, and updating query templates.
- Demonstrate advanced technical ability with 3M/360, Life Chart, and other online programs.
- Test technical platforms as needed.
- Assist with EPIC work queue management, including WQ 21480 Retrospective Reviews.
- Develop complex queries and assist with developing staff capability in this area.
- Perform follow-ups on coding retrospective queries as necessary.
- Perform the duties of a Clinical Documentation Specialist and standard CDI reviews according to productivity expectations.
- Complete 20–24 reviews per day, including review of more complex cases.
- Perform other duties as assigned.
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What This Job Offers
Job Type
Full-time
Career Level
Senior
