[Hiring] Concurrent Clinical Documentation Integrity Specialist @Tufts Medicine

Role Description

This role focuses on activities related to revenue cycle operations such as billing, collections, and payment processing. In addition, this role focuses on performing the following CDI related duties:

• Facilitates improvement in overall quality, completeness, and accuracy of medical record documentation.
• Obtains appropriate clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, and coding staff.
• Serves as a resource to all team members on documentation guidelines.
• Provides guidance and support as well as assisting in the education and training related to improving clinical documentation.
• Oversees the design, implementation or delivery of processes, programs, and policies using specialized knowledge and skills.
• Applies broad theoretical job knowledge typically obtained through advanced education.

This position is responsible for enhancing the quality, accuracy, completeness, and integrity of clinical documentation within the medical record. Responsibilities include:

• Conducting high volume, concurrent reviews of inpatient medical records to identify opportunities for improved clinical documentation accuracy.
• Identifying documentation opportunities, facilitating compliant clinical documentation clarification, and supporting accurate coding.
• Ensuring the medical record accurately represents the patient's clinical condition while supporting organizational performance.
• Meeting established productivity goals and maintaining a minimum quality review score of 95%.

Qualifications

• Associate’s degree in related healthcare field (e.g., medical coding and billing programs, nursing programs, healthcare admin).
• One (1) year of Clinical Documentation Integrity (CDI) experience in an acute care setting; OR
• One (1) year of acute care clinical experience (ICU, Emergency Department, Critical Care, or Medical-Surgical specialties), case management, utilization review, or denials management.
• Active, unrestricted Registered Nurse (RN) license in Massachusetts; OR
• A Nurse Licensure Compact (NLC) state; OR
• AHIMA Certified Coding Specialist (CCS) credential; OR
• AAPC Certified Inpatient Coder (CIC).

Preferred Qualifications

• Bachelor’s degree in nursing (BSN) or Registered Health Information Administrator (RHIA) credential.
• Two (2) years of Clinical Documentation Integrity (CDI) experience in an acute care setting.
• Certified Clinical Documentation Specialist (CCDS) and/or Clinical Documentation Improvement Practitioner (CDIP) certification.

Duties and Responsibilities

• Performs initial and subsequent concurrent reviews of electronic medical record to identify documentation opportunities.
• Evaluates the medical record for completeness, consistency, precision, and clarity.
• Identifies query opportunities for provider clarification and issues compliant, clinically supported queries.
• Exercises professional judgment to determine when provider queries are warranted.
• Maintains alignment with coding professionals by staying current with coding guidelines.
• Accurately documents reviews and other pertinent information in designated systems.
• Exhibits strong critical thinking skills and medical knowledge of disease processes.
• Responsible for effective time management and efficient prioritization.
• Takes proactive steps toward problem solving and troubleshooting of technology errors.

Physical Requirements

• Professional office environment with typical office requirements such as computers, phones, photocopiers, filing cabinets, etc.
• Largely a sedentary role, involving sitting most of the time, but may involve movements such as walking, standing, and reaching.
• Frequently required to speak, hear, communicate, and exchange information.
• Able to see and read computer displays and distinguish letters, numbers, and symbols.
• Occasionally lift and/or move up to 25 pounds.

Skills & Abilities

• Ability to read and write in the English language and communicate fluently.
• Strong critical thinking skills and sound clinical background.
• Ability to analyze and interpret clinical information in the patient’s medical record.
• Excellent verbal and written communication skills with strong attention to detail.
• Knowledge of ICD-10, AHIMA and Coding Guidelines, healthcare regulations, reimbursement, and documentation requirements.
• Open, flexible, and adaptable to a changing environment.
• High level of computer literacy and efficiency with technology.
• Ability to use good judgment in emergency situations.

Pay Range

$40.53 - $51.67 based on full-time equivalent.