Clinical Documentation Specialist II- RN- Remote

Beth Israel Lahey Health (BILH) is a comprehensive, integrated health system serving communities across eastern Massachusetts and southern New Hampshire. Our network includes 14 hospitals—spanning academic medical centers, teaching hospitals, community hospitals, and specialty hospitals —along with over 5,900 physicians and 36,000 employees dedicated to advancing care, research, and education. Beyond our hospitals, BILH provides a full continuum of care, including an extensive primary care network, urgent care centers, specialty care, and the largest behavioral health and substance use disorder network in eastern Massachusetts. We also offer continuing care services, including home health, skilled nursing, and rehabilitation, ensuring patients receive seamless, high-quality care wherever they need it. At BILH, we are committed to creating healthier communities—one person at a time—through patient-centered care, groundbreaking science, and a shared mission of excellence, innovation, and equity.

When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives. **This position is remote. Candidates must be local to New England States for consideration** 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.

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.