[Hiring] Clinical Documentation Specialist I (CDI) @Tufts Medicine

Role Description

The position is responsible for review and analysis of the medical record to improve overall quality and completeness of clinical documentation. The position facilitates and obtains appropriate modifications to clinical documentation, including clinical conditions and procedures, for accurate representation of severity of illness, expected risk of mortality, and complexity of care of the patient through extensive interaction with physicians, HIM professionals, and other interdisciplinary team members.

Qualifications

• Associate’s degree in Nursing
• Active Registered Nurse (RN) license in Massachusetts or compact state
• Five (5) years’ experience in an acute-care hospital setting (ICU, ED, Critical Care, strong Med/Surg Specialty) OR case management, utilization review, or denials management in an acute-care hospital setting
• Bachelor’s degree in nursing (preferred)

Requirements

• Performs initial concurrent review of new patients every day and concurrent re-reviews approximately every two days until the patient is discharged except weekends and company-approved holidays.
• Evaluates the medical record for completeness, consistency, precision, clarity, and legibility. Aligns with the coding professionals by maintaining knowledge of the current Coding Guidelines, ongoing communication, and serving as a liaison between physicians and coders.
• Thoroughly documents reviews, query follow up, and other pertinent information in designated systems by established deadlines.
• Exhibits strong critical thinking skills and medical knowledge of disease processes with an exceptional ability to integrate knowledge. Ability to analyze complex clinical information to identify areas within the medical record for potential gaps in physician documentation.
• Identifies opportunities and provides rationale with supported clinical criteria such as pathology of disease processes, diagnostic findings, lab values, and signs/symptoms and/or coding guidelines when applicable and forwards such discrepancies to management staff in a timely manner for resolution.
• Provides relevant feedback and compliant, clinically credible clarifications with the ability to communicate clearly, proactively, and concisely when interacting with physicians.
• Provides education to physicians and other members of the patient care team to ensure their understanding of the clarification process and the desired outcome of documentation excellence for severity of illness and intensity of care. Provides feedback and education in proficient verbal and written formats both remotely and onsite.
• Simultaneously uses multiple technologies to complete unique patient reviews.
• Responsible for effective time management and efficient prioritization to achieve and maintain key operating metrics consistent with CDI Department needs and requirements.
• Independently takes proactive steps toward problem solving, conflict resolution, and troubleshooting of technology errors.
• Responsible for self-development and completes all mandatory and assigned education by established deadlines.
• Attends scheduled meetings and continuing education programs.
• Actively encourages collaboration and possesses excellent interpersonal skills in building and maintaining crucial relationships.

Benefits

• Comprehensive Total Rewards package that supports your health, financial security, and career growth.
• Fair, competitive pay designed to attract, retain, and motivate highly talented individuals.
• Base pay range: $84,300.22 - $107,481.20.