Job Description:

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Clinical Documentation Specialist RN (40hr, Hybrid Remote/On-site)

Department Description: Beth Israel Deaconess Hospital-Needham (BID-Needham) is a licensed 58-bed acute care community hospital. BID-Needham has served residents in Needham, Newton, Dedham, Dover, Medfield, Sherborn, Wellesley, Westwood and other surrounding communities for more than 100 years. The hospital has been recognized by several organizations for quality and safety, including the Gold Seal of Approval from The Joint Commission and a first-place Accountable Care Compass Award from the Massachusetts Health & Hospital Association (MHA).
BID-Needham is part of Beth Israel Lahey Health, a new health care system that brings together academic medical centers and teaching hospitals, community and specialty hospitals, more than 4,000 physicians and 35,000 employees in a shared mission to expand access to great care and advance the science and practice of medicine through groundbreaking research and education.
BID Needham has had a direct affiliation with Beth Israel Deaconess Medical Center since 2000, facilitating the clinical integration of staff and resources in emergency medicine, hospital medicine (hospitalists), cardiology, radiology, orthopedics, pathology, as well as many surgical services and oncology housed in the Beth Israel Deaconess Cancer Center and Surgical Pavilion.

Job Location: Needham, Massachusetts

Req ID: 43071BR


Job Summary: The Clinical Documentation Specialist is responsible for documentation improvement and integrity and serves as a liaison between clinical care providers, finance, and coders. This role is also an information and educational resource. Position works closely with both clinicians and outside consultants.

Essential Responsibilities:

1. Reviews inpatient medical records concurrently to ensure that the care of the patient is recorded in language that payers can interpret and which accurately and completely depicts acuity of the patient and resources expended. Reviews surgical procedures to ensure documentation is accurate for ICD/10-PCS code assignments.


2. Evaluates documentation for assignment of working and possible DRG.


3. Recognizes opportunities for documentation improvement including severity of illness, risk of mortality, core measures, and patient safety/quality.


4. Queries physicians regarding missing, unclear or conflicting documentation. Requests and obtains additional documentation when needed. Follows up on all unanswered queries.


5. Facilitates modifications to physician documentation to reflect the complexity of care of the patient and appropriate reimbursement.


6. Operationalizes and institutionalizes documentation practice that accurately and completely depicts acuity of the patient and resources expended. All methods adhere to coding clinic and hospital compliance guidelines.


7. Create and implement training and development for nursing staff, physicians and mid-level practitioners that addresses documentation issues & variances.


8. Maintains a collaborative working relationship with the Health Information Coding staff and serves as a clinical resource.


9. Collaborates with and educates members of the patient care team regarding documentation guidelines, including physicians, allied health practitioners, nursing and case management.


10. Demonstrates an understanding of the importance of, and makes an effort to capture, all appropriate secondary diagnoses for quality rating purposes. Maintains review worksheet on all records using CDI software.

Required Qualifications:

1. Associate's degree in Nursing required. Bachelor's degree in Nursing preferred.


2. License Registered Nurse required.


3. 3-5 years related work experience required in a clinical nursing practice, which includes medical, surgical and/or ICU background.


4. Strong critical thinking skills and the ability to review the medical record to identify information not yet documented but supported by clinical indicators or clinical issues.


5. Strong organization skills and attention to detail.


6. Experience with computer systems required, including web based applications and some Microsoft Office applications which may include Outlook, Word, Excel, PowerPoint or Access.

Competencies:

1. 
   Decision Making: Ability to make decisions that are guided by general instructions and practices requiring some interpretation. May make recommendations for solving problems of moderate complexity and importance.


2. 
   Problem Solving: Ability to address problems that are varied, requiring analysis or interpretation of the situation using direct observation, knowledge and skills based on general precedents.


3. 
   Independence of Action: Ability to follow precedents and procedures. May set priorities and organize work within general guidelines. Seeks assistance when confronted with difficult and/or unpredictable situations. Work progress is monitored by supervisor/manager.


4. 
   Written Communications: Ability to summarize and communicate in English moderately complex information in varied written formats to internal and external customers.


5. 
   Oral Communications: Ability to comprehend and communicate complex verbal information in English to medical center staff, patients, families and external customers.


6. 
   Knowledge: Ability to demonstrate full working knowledge of standard concepts, practices, procedures and policies with the ability to use them in varied situations.


7. 
   Team Work: Ability to work collaboratively in small teams to improve the operations of immediate work group by offering ideas, identifying issues, and respecting team members.


8. 
   Customer Service: Ability to provide a high level of customer service to patients, visitors, staff and external customers in a professional, service-oriented, respectful manner using skills in active listening and problem solving. Ability to remain calm in stressful situations.

Physical Nature of the Job:
Light work: Exerting up to 20 pounds of force frequently to move objects. Some elements of the job are sedentary, but the employee will be required to stand for periods of time or move through out the hospital campus


EOE Statement

BIDMC is EOE M/F/VET/DISABILITY/GENDER IDENTITY/SEXUAL ORIENTATION

Vaccines

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. BILH requires that all staff be vaccinated against influenza (flu) and COVID-19 as a condition of employment. Learn more about this requirement

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