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Beth Israel Deaconess Medical Center Clinical Documentation Specialist (CDI) in Boston, Massachusetts

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Clinical Documentation Specialist (CDI)

Department Description:The Clinical Documentation Specialist is responsible for documentation improvement and integrity and serves as a liaison between clinical care providers, finance, and coders.

Job Location:Boston, Massachusetts

Req ID:43638BR

Job Summary:The Clinical Documentation Specialist is responsible for documentation improvement and integrity and serves as a liaison between clinical care providers, finance, and coders. This role is also an information and educational resource, providing proactive review of the Federal Register and new contracts as they relate to coding and reimbursement.

Essential Responsibilities:

  • Reviews inpatient medical records concurrently to ensure that the care of the patient is recorded in language that payers can interpret and which accurately and completely depicts acuity of the patient and resources expended. Reviews surgical procedures to ensure documentation is accurate for ICD/10-PCS code assignments.

  • Operationalizes and institutionalizes documentation practice that accurately and completely depicts acuity of the patient and resources expended. All methods adhere to coding clinic and hospital compliance guidelines.

  • Create and implement training and development for nursing staff, physicians and mid-level practitioners that addresses documentation issues & variances.

  • Develops, maintains and improves upon effective and accurate IS systems for managing, tracking, and analyzing data (including working with Fiscal IS Decision Support).

  • Tracks DRG assignments against national benchmarks to identify documentation variances. Identifies potential solutions, whether general education or targeted interventions, where inconsistencies can be improved upon and rectified.

  • Reviews payer denials. Assists in the preparation of appeals to payers, where appropriate. Develops an intervention to prevent subsequent denials for the same problem, where ambiguity or incompleteness of documentation has led to a denial.

  • Provides ongoing education to coders on clinical topics. Periodically reviews and updates coding clinic guidelines.

Required Qualifications:

  • Associate's degree required. Bachelor's degree preferred.

  • License Registered Nurse required.

  • 3-5 years related work experience required in a clinical nursing practice, which includes medical, surgical and/or ICU background.

  • Experience with computer systems required, including web based applications and some Microsoft Office applications which may include Outlook, Word, Excel, PowerPoint or Access.

Preferred Qualifications:

  • BS in Nursing with 5-8 years of acute care clinical experience.

  • Certified Clinical Documentation Specialist (CCDS) or Certified Clinical Documentation Improvement Professional (CDIP).

  • Experience with DRG Reimbursement and ICD-10 Coding.

Competencies:

  • Decision Making:Ability to make decisions that are guided by precedents, policies and objectives. Regularly makes decisions and recommendations on issues affecting a department or functional area.

  • Problem Solving:Ability to address problems that are highly varied, complex and often non-recurring, requiring staff input, innovative, creative, and Lean diagnostic techniques to resolve issues.

  • Independence of Action:Ability to set goals and determines how to accomplish defined results with some guidelines. Manager/Director provides broad guidance and overall direction.

  • Written Communications:Ability to summarize and communicate in English moderately complex information in varied written formats to internal and external customers.

  • Oral Communications:Ability to comprehend and communicate complex verbal information in English to medical center staff, patients, families and external customers.

  • Knowledge:Ability to demonstrate in-depth knowledge of concepts, practices and policies with the ability to use them in complex varied situations.

  • Team Work:Ability to act as a team leader for small projects or work groups, creating a collaborative and respectful team environment and improving workflows. Results may impact the operations of one or more departments.

  • Customer Service:Ability to provide a high level of customer service and staff training to meet customer service standards and expectations for the assigned unit(s). Resolves service issues in the assigned unit(s) in a timely and respectful manner.

Physical Nature of the Job:

Light work: Exerting up to 20 pounds of force frequently to move objects. Some elements of the job are sedentary, but the employee will be required to stand for periods of time or move through out the hospital campus

EOE Statement

BIDMC is EOE M/F/VET/DISABILITY/GENDER IDENTITY/SEXUAL ORIENTATION

Vaccines

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. BILH requires that all staff be vaccinated against influenza (flu) and COVID-19 as a condition of employment.Learn more (https://www.bilh.org/in-the-news/2021/8/10/bilh-to-require-covid-19-influenza-vaccines-for-all-clinicians-staff-by-oct-31) about this requirement

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