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Rn Clin Doc Specialist
3 months ago
Working under the leadership of the Community Site Director, Clinical Documentation Integrity, the CDI specialist will provide a key role in contributing to the long-term success of the Mass General Brigham CDI program by assisting with day-to-day duties of the Wentworth-Douglass (WDH) CDI team.
The CDI Specialist facilitates improvement in the overall quality, completeness, and accuracy of medical record documentation by performing concurrent medical record reviews and addressing incomplete documentation with members of the clinical team.
- Carries out concurrent medical record reviews for identified payer populationsas directed on admission and throughout hospitalization and for clinical documentation improvement opportunities in the acute care setting.
- Performs accurate and timely concurrent review of selected inpatient admissions to include assignment of working DRG through identification of principal diagnosis and secondary diagnoses including conditions qualifying as complication/co-morbidities and major complications and that impact severity of illness (SOI), risk of mortality (return on investment) and quality measures
- Use clinical insight and judgment of clinical findings to assess clinical documentation for improvement opportunities.
- Communicates effectively with the coding to acquire, interpret, and transmit accurate diagnoses and procedures
- Utilizes CDI software systems to document, track, and report outcomes.
- Participates in unit/organizational programs as needed
- Maintain professional competency by keeping abreast of new coding issues and guidelines.Attends classes and meetings as assigned.Reviews professional CDI and coding literature regularly.
- Approaches conflict in a constructive manner, helps identify problems, offer solutions, and participate in resolution
- Other duties as assigned
- Use the Mass General Brigham values to govern decisions, actions and behaviors. These values guide how we get our work done: Patients, Affordability, Accountability & Service Commitment, Decisiveness, Innovation & Thoughtful Risk; and how we treat each other: Diversity & Inclusion, Integrity & Respect, Learning, Continuous Improvement & Personal Growth, Teamwork & Collaboration
**Qualifications**
- Registered Nurse with a current RN license
- 5 years of acute medical/surgical care nursing preferred
- 3 years of clinical documentation improvement experience preferred
- Certification in Clinical Documentation preferred
- A combination of education and experience may be substituted for requirements
**Primary Location**:NH-Dover-WDH Broadway
**Work Locations**:
WDH Broadway
121 Broadway
Dover03820
**Job**:Medical Records/Coding/HIM - Other
**Organization**:Wentworth-Douglass Hospital(WDH)
**Schedule**:Full-time
Standard Hours:40
**Shift**:Day Job
Posted Shift Description:M-F8-4:30
**Employee Status**:Regular
Recruiting Department:WDH Coding
**Job Posting**:Jun 17, 2024
