Documentation Specialist

General Summary/ Overview: Summarize the nature and level of work performed.

The Clinical Documentation Integrity (CDI) Specialist facilitates improvement in the overall quality, completeness, and accuracy of health record documentation by performing concurrent health record reviews and addressing incomplete and/or inconsistent documentation with members of the clinical team. Indirectly assures DRG assignment and severity/mortality profiles are accurate.

Principal Duties and Responsibilities: Indicate key areas of responsibility, major job duties, special projects and key objectives for this position. These items should be evaluated throughout the year and included in the written annual evaluation.

Improve the quality of clinical documentation in the health record to support appropriate DRG assignment and accurately reflect the severity of illness and risk of mortality for each patient.

Perform concurrent CDI reviews for designated patient populations in the acute care setting resulting in the identification of clinical documentation improvement opportunities.

Apply clinical knowledge and insight to assess clinical findings, validate integrity of clinical documentation and query provider(s) for clarification, as applicable.

Work collaboratively with medical, nursing and ancillary staff, including coding professionals, to resolve identified clinical documentation deficiencies and support accurate outcomes reporting.

Meet or exceed MGB Clinical Documentation Integrity Specialist key performance indicators (KPIs).

Assign working DRG based on industry standard coding guidelines and regulations.

Bachelor's degree in nursing required

RN with a current license required

5 -7 years of acute medical/surgical care nursing required

1-2 years Critical Care nursing preferred

3-5 years of clinical documentation integrity experience required

Certification in Clinical Documentation preferred

1-2 years of computer and data entry required