Top 43 Clinical documentation improvement specialist Jobs in Massachusetts

Clinical Documentation Improvement Specialist
Beth Israel Lahey Health —Charlestown, MA
- $102,000 - $158,392 a year
- Full-time
- Nursing
- Microsoft Excel
- Microsoft Outlook
Clinical Documentation Specialist I-CDI
Beth Israel Lahey Health —Winchester, MA
- $85,000 - $132,000 a year
- Full-time
- Nursing
- Microsoft Excel
- Microsoft Outlook
Clinical Documentation Specialist II- RN- Remote
Beth Israel Lahey Health —Charlestown, MA
- $102,000 - $158,392 a year
- Full-time
- Remote
- Nursing
- Microsoft Excel
- Microsoft Outlook
Inpatient Clinical Documentation Integrity Risk Adjustment Specialist
Mass General Brigham Incorporated —Somerville, MA
- $79,560.00 - $115,720.80 a year
- Full-time
- Remote
- RN License
- Research
- 3 years
- Opportunities for advancement
Quick Apply
Regional Quality Measure Specialist
AMA-LTC —Boston, MA
- From $110,000 a year
- Full-time
- Hybrid work
- Background check
- Skilled nursing facility
- RN License
- Health insurance
- Dental insurance
Quick Apply
Professional Billing- Coding/Education Specialist - REMOTE
UMass Memorial Health —Worcester, MA
- $64,084.80 - $115,336.00 a year
- Full-time
- Hybrid work
- Research
- Mid-level
- Analysis skills
- Health savings account
- Health insurance
Quick Apply
Senior Consultant - Clinical Documentation Specialist
Deloitte —Boston, MA
- $110,700 - $218,300 a year
- Full-time
- Microsoft Word
- Nursing
- RN License
Clinical Audit Response Specialist
Dana-Farber Cancer Institute —Boston, MA
- $110,200 - $122,300 a year
- Full-time
- Nursing
- RN License
- 5 years
Medical Staff Office Specialist
Beth Israel Lahey Health —Woburn, MA
- $31.63 - $41.73 an hour
- Full-time
- Hospital
- Customer service
- Mid-level
Regional Clinical Reimbursement Specialist
CareOne —Millbury, MA
- $140,000 - $155,000 a year
- Nursing
- Skilled nursing facility
- RN License
- Commuter assistance
- Health savings account
Quick Apply
Billing Specialist (160)
Lifeworks, Inc. —Westwood, MA
- $27 - $30 an hour
- Part-time
- Background check
- Experience working with individuals with developmental disabilities
- CPR Certification
- Dental insurance
Quick Apply
13d
Inpatient Coding Quality & Education Specialist
Mass General Brigham Incorporated —Somerville, MA
- $63,648.00 - $92,570.40 a year
- Full-time
- Project management
- Travel
- Mentoring
- Opportunities for advancement
Quick Apply
10d
SIU Code Auditor
Fallon Health —Worcester, MA
- $87,500 a year
- Full-time
- Writing skills
- Mid-level
- 3 years
10d
Outpatient Coder 2
Beth Israel Lahey Health —Charlestown, MA
- $22.43 - $45.41 an hour
- Full-time
- Microsoft Excel
- Surgery
- Computer literacy
Provider Optimization Specialist, Same Day Services - Optum MA
Optum —Auburndale, MA
- Full-time
- Medicine
- BLS Certification
- Pass drug screening
- Paid time off
Quick Apply
Outpatient Coder 3
Beth Israel Lahey Health —Charlestown, MA
- $29.80 - $47.68 an hour
- Full-time
- Microsoft Excel
- Surgery
- 5 years
Senior Revenue Cycle and Accounts Receivable Specialist
Terra Fertility PLLC —Dedham, MA
- $35 - $45 an hour
- Full-time
- Finance
- Analysis skills
- Bachelor's degree
- Paid holidays
- Health insurance
Maintenance Support Technician II, 40hr Flex
UMass Memorial Health Care —Worcester, MA
- $23.81 - $35.08 an hour
- 8 hour shift
- Remote
- Mid-level
- 3 years
- High school diploma or GED
14d
HIM Specialist- Full Time Temporary
Lynn Community Health Center —Lynn, MA
- $18.13 - $23.92 an hour
- Temporary
- Spanish
- Computer literacy
- English
Quick Apply
Billing Specialist
Veterans Inc. —Shrewsbury, MA
- From $26.44 an hour
- Online Application
- HIPAA
- Research
- 3 years
- 403(b) matching
- Paid parental leave
Quick Apply

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Clinical Documentation Improvement Specialist

Beth Israel Lahey Health -
Charlestown, MA

Apply Now

Job Details

Full-time
$102,000 - $158,392 a year

Qualifications

Medical writing
RN License
Bachelor's degree
Medical-surgical
Desktop applications
Bachelor's degree in nursing
Clinical documentation improvement

Full Job Description

Charlestown, MA • Beth Israel Lahey Health • Full-time • Day

When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives.

The Clinical Documentation Improvement (CDI) Specialist II assists with the appropriate identification of diagnoses, conditions, and/or procedures that are representative of the patient’s hospital stay and care provided including Severity of Illness (SOI), Risk of Morality (ROM), during an inpatient hospitalization. CDI Specialist II initiates concurrent queries to providers as supported by medical record documentation to improve the accuracy, integrity, and quality of patient data, and drive improvement toward quality physician documentation within the body of the medical record. The CDI Specialist II works under the direction of the Manager of CDI and collaborates with coding, clinicians, medical staff, and physician advisors to improve documentation and the importance of complete and accurate documentation.

Job Description:

Essential Duties & Responsibilities including but not limited to:

Concurrently reviews inpatient records to ensure completeness, accuracy, and clinical validation.
Evaluates documentation for assignment of working and possible DRG.
Recognizes opportunities for documentation improvement, including severity of illness, risk of mortality, core measures, and patient safety/quality.
Identify opportunities to query physicians regarding missing, unclear, or conflicting documentation.
Interacts directly with physicians to request and obtain additional documentation when needed.
Timely follow-up on all unanswered queries based on the query escalation policy.
Facilitates modifications to physician documentation to reflect the complexity of care of the patient and appropriate reimbursement.
Maintains a collaborative working relationship with the Health Information Coding staff and serves as a clinical resource.
Collaborates with and educates members of the patient care team regarding documentation guidelines, including physicians, allied health practitioners, nursing, and case management.
Performs mortality reviews and optimizes the risk of mortality.
Maintains review worksheet on all records using CDI software.
Ensures the accuracy of clinical information used for measuring and reporting physician and hospital quality outcomes.
Reviews, evaluates, analyzes, and interprets data related to documentation on an ongoing basis. Identifies trends or potential problems and assists in developing action plans to address.
Participates in additional projects such as developing physician education materials, CDI week advertisements, etc.
Adheres to ethical and professional business practices.
All other duties as assigned.
It is understood that this is a summary of key job functions and does not include every detail of the job that may reasonably be required.

Minimum Qualifications:

Education:

Bachelor’s in Nursing, required

Licensure, Certification & Registration:

RN License
Clinical Documentation Specialist Certification via ACDIS or AHIMA

Experience:

2-5 years of medical/surgical nursing experience in the acute hospital setting.
Critical Care and/or Emergency Nursing experience required

Skills, Knowledge & Abilities:

Proficient skill in query writing to physicians
Knowledge to accurately complete chart audits
Organizational and critical thinking skills required
Experience with computer systems required, including web-based applications and some Microsoft Office applications which may include Outlook, Word, Excel, PowerPoint, or Access

Pay Range:

$102,000.00 USD – $158,392.00 USD

The pay range listed for this position is the annual base salary range the organization reasonably and in good faith expects to pay for this position at this time. Actual compensation is determined based on several factors, that may include seniority, education, training, relevant experience, relevant certifications, geography of work location, job responsibilities, or other applicable factors permissible by law.

As a health care organization, we have a responsibility to do everything in our power to care for and protect our patients, our colleagues and our communities. Beth Israel Lahey Health requires that all staff be vaccinated against influenza (flu) as a condition of employment.

More than 35,000 people working together. Nurses, doctors, technicians, therapists, researchers, teachers and more, making a difference in patients' lives. Your skill and compassion can make us even stronger.

Equal Opportunity Employer/Veterans/Disabled

Job details

Employment: Full-time
Hours/Week: 40
Shift: Day
Category: Clinical Documentation Improvement (CDI)
Pay Range: $102,000.00 USD - $158,392.00 USD
FLSA: Exempt
Req ID: JR93008

Apply Now

Refine Your Search

clinical documentation improvement specialist jobs in massachusetts

Clinical Documentation Improvement Specialist

Clinical Documentation Specialist I-CDI

Clinical Documentation Specialist II- RN- Remote

Inpatient Clinical Documentation Integrity Risk Adjustment Specialist

Regional Quality Measure Specialist

Professional Billing- Coding/Education Specialist - REMOTE

Senior Consultant - Clinical Documentation Specialist

Clinical Audit Response Specialist

Medical Staff Office Specialist

Regional Clinical Reimbursement Specialist

Billing Specialist (160)

Inpatient Coding Quality & Education Specialist

SIU Code Auditor

Outpatient Coder 2

Provider Optimization Specialist, Same Day Services - Optum MA

Outpatient Coder 3

Senior Revenue Cycle and Accounts Receivable Specialist

Maintenance Support Technician II, 40hr Flex

HIM Specialist- Full Time Temporary

Billing Specialist

I want to receive the latest job alert for clinical documentation improvement specialist in massachusetts

Explore jobs in more locations

As a health care organization, we have a responsibility to do everything in our power to care for and protect our patients, our colleagues and our communities. Beth Israel Lahey Health requires that all staff be vaccinated against influenza (flu) as a condition of employment.

More than 35,000 people working together. Nurses, doctors, technicians, therapists, researchers, teachers and more, making a difference in patients' lives. Your skill and compassion can make us even stronger.

Equal Opportunity Employer/Veterans/Disabled

Job details

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