Brigham and Women's Hospital
Documentation Specialist
Brigham and Women's Hospital, Boston, Massachusetts, us, 02298
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:
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.
Qualifications:
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
EEO Statement:
BWH is an Affirmative Action Employer. By embracing diverse skills, perspectives, and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.
Primary Location:
MA-Boston-BWH Boston Main Campus
Work Locations:
BWH Boston Main Campus, 75 Francis St, Boston, 02115
Job:
Nursing-Other
Organization:
Brigham & Women's Hospital(BWH)
Schedule:
Full-time
Standard Hours:
40
Shift:
Day Job
Employee Status:
Regular
Recruiting Department:
MGB Office of the Chief Medical Officer
Job Posting:
Dec 3, 2024
#J-18808-Ljbffr
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:
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.
Qualifications:
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
EEO Statement:
BWH is an Affirmative Action Employer. By embracing diverse skills, perspectives, and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.
Primary Location:
MA-Boston-BWH Boston Main Campus
Work Locations:
BWH Boston Main Campus, 75 Francis St, Boston, 02115
Job:
Nursing-Other
Organization:
Brigham & Women's Hospital(BWH)
Schedule:
Full-time
Standard Hours:
40
Shift:
Day Job
Employee Status:
Regular
Recruiting Department:
MGB Office of the Chief Medical Officer
Job Posting:
Dec 3, 2024
#J-18808-Ljbffr