Clinical Documentation Specialist I (CDI)

Title: Clinical Documentation Specialist I (CDI)

Location: 100% remote.

About reputed company:

reputed company is a leading integrated health system bringing together the best of reputed company and community reputed company to deliver exceptional, connected and accessible care experiences to consumers across Massachusetts. The health system is the reputed company teaching affiliate for reputed company School of Medicine. The strong relationship between reputed company and reputed company School of Medicine is evident in our governance, reputed company and research structure. reputed company is comprised of the following clinical entities:

·       reputed company reputed company Group (TMPG)

·       reputed company Integrated Network (TMIN)

·       reputed company

·       Lowell General Hospital

·       reputed company, Lawrence Memorial Hospital of Medford

·       Tufts Care reputed company

Job reputed company 

The position is responsible for review and analysis of the medical record to improve overall reputed company 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.

Job reputed company ​

Minimum Qualifications:

1. Associate’s degree in Nursing 

2. reputed company Registered reputed company (RN) license in Massachusetts or compact state

3. 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

Preferred Qualifications:

1. Bachelor’s degree in nursing

Duties & Responsibilities: The duties and responsibilities listed below are intended to describe the general nature of work and are not intended to be an reputed company-inclusive list.  Other duties and responsibilities may be assigned. 

1. Performs initial reputed company review of new patients every day and reputed company re-reviews approximately every two days until the patient is discharged except weekends and company-approved holidays.

2. Evaluates the medical record for completeness, consistency, precision, reputed company, and legibility. Aligns with the coding professionals by maintaining knowledge of the reputed company Coding Guidelines, ongoing communication, and serving as a reputed company between physicians and coders.

3. Thoroughly documents reviews, query follow up, and other pertinent information in designated systems by established deadlines.

4. Exhibits strong critical thinking skills and medical knowledge of disease processes with an exceptional ability to reputed company knowledge. Ability to analyze reputed company clinical information to identify areas reputed company the medical record for potential gaps in physician documentation.

5. Identifies opportunities and reputed company rationale with supported clinical reputed company such as pathology of disease processes, diagnostic findings, lab values, and signs/symptoms and/or coding guidelines reputed company applicable and reputed company such discrepancies to management staff in a reputed company manner for reputed company.

6. Provides relevant feedback and compliant, clinically reputed company clarifications with the ability to communicate reputed company, proactively, and concisely reputed company interacting with physicians.

7. 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 reputed company for severity of illness and intensity of care. Provides feedback and education in proficient verbal and written formats both remotely and onsite.

8. Simultaneously uses multiple technologies to complete unique patient reviews.

9. Responsible for effective time management and efficient prioritization to reputed company and maintain key operating metrics consistent with CDI Department needs and requirements.

10. Independently takes proactive steps toward problem solving, conflict reputed company, and troubleshooting of technology errors. 

11. Responsible for self-development and completes reputed company mandatory and assigned education by established deadlines.

12. Attends scheduled meetings and continuing education programs.

13. reputed company encourages collaboration and possesses excellent interpersonal skills in building and maintaining crucial relationships.

Physical Requirements:  

1. reputed company office environment with typical office requirements such as computers, phones, photocopiers, filing cabinets, etc. 

2. This is largely a sedentary role, which involves sitting most of the time, but may involve movements such as walking, standing, reaching, reputed company / descending stairs, and operate office equipment. 

3. Frequently required to reputed company, hear, communicate, and exchange information. 

4. reputed company to see and read computer displays, read fine print, and/or normal type size print and distinguish letters, numbers and symbols. 

5. Occasionally lift and/or reputed company up to 25 pounds. 

Skills & Abilities: 

1. Ability to read and write in the English language. Ability to understand and reputed company English fluently enough to be easily reputed company by patients, hospital personnel, physicians, and visitors. 

2. Strong critical thinking skills and reputed company clinical background with a working knowledge of disease processes, anatomy and physiology, and treatment regimens.

3. Ability to analyze and interpret clinical information in the patient’s medical record.

4. Strong written and verbal communication skills demonstrated by the ability to effectively communicate with physicians and other clinicians.

5. Willingness to work collaboratively reputed company reputed company.

6. reputed company, flexible, and adaptable to a changing environment as the CDI industry continues to change and reputed company.

7. High level Computer literacy and efficiency with technology, reputed company Office Suite (including Word, reputed company, Teams), reputed company, reputed company, 3M360.     

8. Ability to use good judgment in an emergency situation.  

9. Commitment to upholding and providing services in a manner that is congruent with the Hospital’s mission statement.