Clinical Documentation Improvement Specialist

Location: 55 Fogg Road, Weymouth, MA 02190. Department: SHS Revenue Integrity. Full‑time, 40 hours per week.

About the role

Under the general supervision of the Manager of Clinical Documentation, the Documentation Specialist assists to develop, implement, and maintain the documentation accuracy initiative at the Hospital. The role involves concurrent review of clinical documentation in the medical record and concurrent querying of medical staff caregivers to obtain accurate and complete documentation that appropriately supports the severity of patient illness. The specialist is on‑site and available five days a week.

Responsibilities

• Perform concurrent review process for all selected admissions to ensure documentation accurately reflects the severity of patient’s illness
• Produce worklists from Epic daily to review case on day 2 as well as daily throughout the patient’s stay
• Review patients admitted and discharged on the weekend in coding before the bill is dropped
• Review all inpatient cases and observation or surgical day cases that have the potential to be converted to an inpatient admission
• Identify and record principal and secondary diagnoses, principal procedures, and assign a working DRG on Documentation worksheet
• Identify need to clarify documentation in records and initiate assertive communication with physician or other care provider using the most appropriate method (physician documentation request, face‑to‑face contact, phone call, etc.)
• Input current DRG into Epic for all Medicare patients daily
• Input and reconcile queries on Excel datasheet daily
• Provide information and education as necessary to physicians and other care providers specific to DAP
• Present overview of program to new physicians and other care providers at orientation
• Follow up with new physicians who document in medical records in a one‑to‑one meeting
• Provide ongoing information/education as necessary to physicians and other care providers not responding to documentation requests
• Assist in providing feedback to medical staff regarding performance as it relates to accuracy of opportunities to improve documentation
• Conduct continual medical staff education as a proactive measure
• Maintain a collaborative working relationship with team and with Health Information Management department staff
• Perform focused reviews, both concurrently and retrospectively, to determine areas where information and/or education may be required for the team or members of the team to improve program effectiveness
• Perform focused reviews, both concurrently and retrospectively, to determine areas where information and/or education may be required for physicians or other care providers to improve program effectiveness
• Share pertinent coding and DRG reference materials (e.g., coding clinics)
• Share pertinent clinical information (e.g., new drugs/treatments)
• Identify improvements needed by physicians with continued documentation needs to medical staff liaison for further action
• Review, evaluate, analyze and interpret data related to documentation from internal and external sources on an ongoing basis
• Identify trends or potential problems and assist in developing action plans to address them
• Track and provide regular (monthly, other) reports for mortality, queries, and case mix in support of hospital‑wide initiatives
• Participate in organizational surveys that evaluate staff perception of safety
• Seek and participate in educational opportunities to improve job skills and program
• Demonstrate knowledge of organizational safety priorities and their department‑specific application, methods of reporting safety concerns and opportunities
• Identify annually at least one implementable idea to improve patient, staff, or environmental safety
• Successfully answer safety questions in annual mandatory education program
• Understand roles/responsibilities during hospital codes
• Adhere to respiratory etiquette guidelines

Requirements

• Minimum Education: Graduate from an accredited school of nursing with a license to practice professional nursing in Massachusetts; BSN preferred
• Minimum Work