At Boston Children’s Hospital, the quality of our care – and our inclusive hospital working environment – lies in the diversity of our people. With patients from local communities and 160 countries around the world, we’re committed to reflecting the spectrum of their cultures, while opening doors of opportunity for our team. Here, different talents pursue common goals. Voices are heard and ideas are shared. Join us, and discover how your unique contributions can change lives. Yours included.
This Clinical Documentation Integrity Specialist will be responsible for:
Facilitating clinical documentation to support appropriate diagnosis coding & to ensure the level of service rendered to all patients is accurately reflected.
Collaborating with HIM coding staff to promote complete & accurate clinical documentation & correct negative trends.
Communicating with physicians, nurse practitioners, case managers, coders & members of the care team to facilitate comprehensive medical record documentation to reflect treatment, decision-making & medical documentation.
Assigning a working APR-DRG, severity of illness & risk of mortality using coding rules & guidelines.
Analyzing clinical information to identify areas within the chart for potential gaps in physician documentation.
Query physicians on a concurrent basis. Work with clinicians to clarify documentation in the medical record.
Formulating credible clinical documentation clarifications to improve clinical documentation of principal diagnosis, co-morbidities, present on admission (POA), quality core measures, & patient safety indicators (PSI).
Conducting post discharge reviews for comparative analysis of CDI Specialist & HIM APR-DRG, adding SOI & ROM assignments. Reviewing clinical issues with the coding staff to assign a working DRG.
Developing and conducting ongoing education for new staff, including new CDI Specialists, physicians & nursing.
Utilizing software systems (including APR-DRG encoder) to collect, track, & report outcomes. Being proficient in abstraction of data and entry into all databases used for clinical documentation. Maintaining integrity of data.
Participating in ongoing education of staff. Developing educational materials & tools relative to documentation improvement practices for individual practitioners & groups of clinicians presented as handouts, PowerPoint, etc.
Working 40 hours, flexibility with schedule. Remote work with in person meetings as needed. Must live MA or the surrounding area.
To qualify you must have:
Bachelor’s Degree (Nursing preferred)
If no nursing background, certification as an inpatient coder or other relevant clinical experience (e.g. MD-equivalent degree) required.
Clinical inpatient hospital experience preferred.
CDI Specialist experience in an inpatient setting, preferred.
Superior communication & interpersonal skills
Competency in MS Office; experience with Cerner EMR preferred.
Knowledge of the APR-DRG and ICD10 coding preferred.
Please note: During a public health emergency, individuals in this role may be expected to take on additional duties to respond to organizational needs.
Boston Children’s Hospital offers competitive compensation and unmatched benefits, including affordable health, vision and dental insurance, generous levels of time off, 403(b) Retirement Savings plan, Pension, Tuition Reimbursement, and discounted rates on T-passes (50% off). Discover your best.
Boston Children’s Hospital is an Equal Opportunity / Affirmative Action Employer. Qualified applicants will receive consideration for employment without regard to their race, color, religion, national origin, sex, sexual orientation, gender identity, protected veteran status or disability.
Internal Number: 59750BR
About Boston Children's Hospital
Boston Children’s Hospital is dedicated to improving and advancing the health and well-being of children around the world through its life-changing work in clinical care, biomedical research, medical education and community engagement.Boston Children's is ranked the number one pediatric hospital in the nation by U.S. News and World Report. It is home to the world's largest pediatric research enterprise, and it is the leading recipient of pediatric research funding from the National Institutes of Health. It is the primary pediatric teaching hospital for Harvard Medical School. Boston Children’s treats more children with rare diseases and complex conditions than any other hospital.