Clinical Documentation Specialist, CDI

The Clinical Documentation Specialist (CDI) acts as a liaison between medical staff, Nursing, Coding and QI specialist to ensure the clinical documentation supports and reflects the most appropriate level of services and resources provided.

This is a remote opportunity. Candidates will be trained via remote meeting tools and resources.

Current States eligible for remote: CT, FL, MD, NH, NC, OH, RI, TN, TX, VT, VA, MA

The Clinical Documentation Specialist provides clinically based concurrent review of inpatient medical records to assess and procure accurate and complete documentation of the patients' diagnoses and procedures

•  Ensures documentation accurately reflects quality of care, severity of illness and risk of mortality to support correct coding, reimbursement and quality initiatives.

•  Proactively contacts physicians or other departments regarding procedures/diagnoses to ensure proper documentation. This includes joining physicians and other clinical staff in educational sessions and "rounds" on the nursing units. Participates, when appropriate, with questions to improve overall documentation of the care being rendered to the patient.

• Identifies opportunities to improve documentation and coding workflow process. Collaborates with the HIM management and staff.

•  Prepares and presents educational sessions to physicians on proper documentation.

• Monitors and participates in performance improvement initiatives.

•  Participates in the planning for assigned inter/intra departmental meetings and presentations

•  Participates in professional development and activities to keep current with trends in coding. This can include offsite meetings/conferences/site visits where travel and overnight stay might be required.

•  Communicates effectively and adaptable to a wide variety of interpersonal environments within the entire healthcare system. Able to be an approachable liaison to facilitate the achievement of CDI goals.

•  All tasks need to be performed following the Operating Principles of Baystate Health. Adheres to system and department compliance policies, and any and all applicable laws and regulations. Performs other duties as assigned.

Required Work Experience: 

• MA Licensed Registered Nurse
• BSN and  5 years’ experience in an acute care setting (Med Surg, ICU, Telemetry, inpatient bedside exp.)
• If Physician trained, RN will not be required
• Anatomy and Physiology Medical Terminology is required.
• Clinical Documentation Specialist and CCS/CDS/ICD preferred.
• Familiarity with Cerner and 3M applications.
• Certifications:  RHIA, RHIT, CDS, CCS - preferred

Skills and Competencies: 

• Extensive clinical knowledge and understanding of pathology/physiology; best demonstrated by clinical experience in hospital setting
• Exceptional skill and comfort with computer navigation, data entry and communications are a must.

SCHEDULE:

• Full Time – 40 weekly hours Monday – Friday
• No weekends no holidays

THE ADVANTAGES OF WORKING WITH BAYSTATE!

• Excellent Compensation High-quality, low-cost medical, dental and vision & life insurance
• Generous PTO
• Continuing education support and reimbursement
• 403b retirement company match & annual company contribution increase based on years of service
• Pet, home, auto and personal insurance
• Reimbursement for a variety of wellbeing activities, included but limited to gym membership and equipment, personal trainer, massage and so much more!
• Wellbeing programs that include but are not limited to mental, physical, and financial health

Baystate Health, western Massachusetts’ only academic center and tertiary care provider has a long and proud tradition of continuous learning and improvement. We educate and train hundreds of healthcare workers every year and advance knowledge about new approaches to care. At Baystate Health we know that treating one another with dignity and equity is what elevates respect for our patients and staff.  We are committed to increasing diverse representation across our organization. Together our inspired and compassionate teams manage the whole health needs of all communities in need.