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Changing health care
to improve quality of
life for all.

Beth Israel Lahey Health’s roots in providing top-quality health care date back nearly a century. We're fully committed to ensuring our patients receive the care they deserve. As a leading healthcare provider throughout New England, we aim to change the current state of health care for the better and make lasting improvements that guarantee access to our services.

Clinical Documentation Specialist (RN)

Milton, Massachusetts

Organization Facility: Beth Israel Lahey Health - Non Executive Category: Clinical Documentation Improvement (CDI) Job ID: JR60910 Date posted: 12/09/2024
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Job Type: Regular

Time Type: Full time

Work Shift: Day (United States of America)

FLSA Status: Exempt

When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives.

This position supports Beth Israel Deaconess Hospital - Milton. The Clinical Documentation Specialist (CDS) provides a key role in facilitating long-term success of the hospital's Clinical Documentation Improvement (CDI) process by implementing the objectives of the CDI program at Beth Israel Deaconess Hospital-Milton on a daily basis. The CDS works in collaboration with the CDI team of clinicians, coding professionals, physicians,
physician's assistants' and nurse practitioners to ensure accurate and timely clinical documentation in the medical record, which in tum supports the coding process in attaining appropriate DRGs based on sound clinical entries in the medical record.
The CDS is responsible for increasing program awareness to the entire hospital staff. The CDS participates in data collection and analysis for quality improvement initiatives. The CDS supports ongoing communication and education on documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies to physicians and
entire hospital staff.
The CDS participates in committees, task forces and other hospital forums that work to provide input and assistance in order to successfully implement and support CDI processes.

Job Description:

Job Description

Essential Duties & Responsibilities including but not limited to: 

1.    Completes initial reviews of patient records within 24–48 hours of admission: (a) evaluate documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate DRG assignment, risk of mortality, and severity of illness; and (b) track review details in 3M software.
2.    Conducts follow-up reviews of patients every 2 days to support and assign a working DRG assignment. 
3.    Queries physicians regarding missing, unclear, or conflicting medical record documentation by requesting and obtaining additional documentation within the medical record when needed.
4.    Educates physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the medical record.
5.    Collaborates with the CDI Manager & Physician Advisor and other ancillary staff regarding interaction with physicians on documentation and to resolve physician queries prior to patient discharge.

6.    Educates members of the patient care team regarding documentation opportunities and best practices to ensure accurate documentation in the medical record.

7.    Applies diplomacy and professionalism when interacting with physicians and clinicians; especially when addressing missing or conflicting medical record information
8.    Works in partnership with an interdisciplinary team to foster collaboration, learning and accurate and complete medical record documentation.
9.    Exhibits working knowledge of inpatient coding guidelines. Adheres to CDI convention and department policies and procedures.
10.    Investigates, evaluates, and identifies opportunities for improvement and recognizes their relative significance in the overall system.
11.    Provides orientation for new clinical staff regarding documentation requirements as required.
12.    Keeps current with CDI concepts and practices through conferences, reference material and review of current literature.
13.    Maintains confidentiality of all customer/hospital information.
14.    Demonstrates flexibility in the face of changing work environment, adjusting work schedule accordingly.

Minimum Qualifications: 

Education: 
Degree in Nursing, Bachelor’s preferred, or comparable education as Medical School graduate. Related Master’s Degree highly desirable.

Licensure, Certification & Registration: 
Current active RN licensure or for Medical School graduate: Required certification from Educational Commission for Foreign Medical Graduates (ECFMG). Certified CDIP, CCDS, CCS highly desirable. 


Experience: Must have at least 5 years acute care hospital level nursing experience (e.g., ER, ICU) or equivalent case management, quality, or utilization review in a hospital setting

Skills, Knowledge, and Abilities  

  • Positive & professional communication skills 
  • High level Computer literacy required: applicable to EMR entry & software program proficiency for CDI workflow. 

As a health care organization, we have a responsibility to do everything in our power to care for and protect our patients, our colleagues and our communities. Beth Israel Lahey Health requires that all staff be vaccinated against influenza (flu) and COVID-19 as a condition of employment. Learn more about this requirement.

More than 35,000 people working together. Nurses, doctors, technicians, therapists, researchers, teachers and more, making a difference in patients' lives. Your skill and compassion can make us even stronger.

Equal Opportunity Employer/Veterans/Disabled

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Why join Beth Israel Lahey Health?

If you’re looking for a career where you can make a difference and explore your potential, Beth Israel Lahey Health is the place you belong. Our system includes a network of hospitals, physician practices, outpatient centers, and other healthcare facilities and we offer a broad range of careers in direct patient care, environmental services, registration, finance and many other fields. We are focused on providing compassionate and personalized healthcare with a strong reputation for clinical excellence and research and offer diverse opportunities for career growth and development. Conveniently, we have many locations in communities across Eastern Massachusetts and Southern New Hampshire.

At Beth Israel Lahey Health, we see you for all that you are – your experience and your dreams. Explore our open opportunities and find out why so many have already chosen to join our team.

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