Documentation Specialist

7 days ago

Boston, United States Mass General Brigham Full time

Description:

General Summary/ Overview: Summarize the nature and level of work performed.

The Clinical Documentation Integrity (CDI) Specialist facilitates improvement in the overall quality, completeness, and accuracy of health record documentation by performing concurrent health record reviews and addressing incomplete and/or inconsistent documentation with members of the clinical team. Indirectly assures DRG assignment and severity/mortality profiles are accurate.

Principal Duties and Responsibilities: Indicate key areas of responsibility, major job duties, special projects and key objectives for this position. These items should be evaluated throughout the year and included in the written annual evaluation.

Improve the quality of clinical documentation in the health record to support appropriate DRG assignment and accurately reflect the severity of illness and risk of mortality for each patient.

Perform concurrent CDI reviews for designated patient populations in the acute care setting resulting in the identification of clinical documentation improvement opportunities.

Apply clinical knowledge and insight to assess clinical findings, validate integrity of clinical documentation and query provider(s) for clarification, as applicable.

Work collaboratively with medical, nursing and ancillary staff, including coding professionals, to resolve identified clinical documentation deficiencies and support accurate outcomes reporting.

Meet or exceed MGB Clinical Documentation Integrity Specialist key performance indicators (KPIs).

Assign working DRG based on industry standard coding guidelines and regulations.

Qualifications:

Bachelors degree in nursing required

RN with a current license required

5 -7 years of acute medical/surgical care nursing required

1-2 years Critical Care nursing preferred

3-5 years of clinical documentation integrity experience required

Certification in Clinical Documentation preferred

1-2 years of computer and data entry required

EEO Statement

BWH is an Affirmative Action Employer. By embracing diverse skills, perspectives, and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.

Primary Location MA-Boston-BWH Boston Main Campus

Work Locations BWH Boston Main Campus 75 Francis St Boston 02115

Job Nursing-Other

Organization Brigham & Women's Hospital(BWH)

Schedule Full-time

Standard Hours 40

Shift Day Job

Employee Regular

Job Posting Dec 3, 2024

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