Clinical Doc Specialist - 40 Hours

Location: Winchester, MA
Job ID: 175959-1A
Date Posted: May 2, 2022

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Job Description

Welcome To

Welcome to Winchester Hospital, part of Beth Israel Lahey Health. Winchester Hospital was the first hospital in Massachusetts to earn Magnet recognition, the American Nurses Association’s highest honor for nursing excellence, three times. It has since received the recognition a fourth time. As the northwest suburban Boston area’s leading provider of comprehensive health care services, the 229-bed facility provides care in general, bariatric and vascular surgery, orthopedics, pediatrics, cardiology, pulmonary medicine, oncology, gastroenterology, rehabilitation, radiation oncology, pain management, obstetrics/gynecology and a Level IIB Special Care Nursery.


About the Job

JOB SUMMARY          

The Clinical Documentation Improvement Specialist (CDIS) promotes the documentation of medical necessity and assists with appropriate identification of diagnoses, conditions and/or procedures that are representative of the patient’s Severity of Illness (SOI), Risk of Mortality (ROM), and resource consumption during an inpatient hospitalization.  CDIS initiates concurrent and retrospective queries as supported by medical record documentation to improve the accuracy, integrity and quality of patient data, minimize variation in the query process and improve the quality of the physician documentation within the body of the medical record.  They collaborate with the Manager of Coding, HIM Coders, medical staff and the Physician Validator to improve documentation and coding and medical staff knowledge of the importance of complete and accurate documentation.




Required:  RN, Bachelor’s degree





 Must have at least 5 years inpatient coding experience and/or an RN or other healthcare clinician with at least 5 years acute care nursing experience (e.g., medical-surgical, ICU, case management, etc.)



Other Skills/Knowledge


Knowledge of payment methodologies, federal and state regulations, organization and communication skills

In-depth knowledge of clinical documentation requirements, DRG assignment, quality indicators and clinical conditions and/or procedures

Computer literate and access applicable software programs for CDI tracking, monitoring

and report generation

Extensive coding and DRG understanding



Preferred: Epic and 3M 360



Required     RN; RN with CDIP, CCDS, CCS, RHIA








Professional Commitment Requirements:  Keep abreast of developments in the field and/or licensure through continuing education, participation in professional organizations or a combination of both.

On-call:  N\A

Schedule requirements:  Based on Business needs

Travel requirements:   Travel within hospital locations may be required



 Reports to the Director of Health Information Management

 Not responsible for supervising the work of others


  • Consistent with the PROMISE principles and inherent in a hospital environment, employees must be flexible in meeting patients’ and the Hospital’s needs. While the list below describes the primary functions of this job, all employees at Winchester Hospital need to recognize that an essential element of their job is the ability to respond to unanticipated and/or changing situations.  This may result in assuming responsibilities or tasks, which are not on this list.


  • Completes initial reviews of patient records within 24–48 hours of admission: (a) evaluate documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate DRG assignment, risk of mortality, and severity of illness; and (b) track review details in 3M CDIS software.


  • Conducts follow-up reviews of patients every 2–3 days to support and assign a working DRG assignment.


  • Queries physicians regarding missing, unclear, or conflicting medical record documentation by requesting and obtaining additional documentation within the medical record when needed.


  • Educates physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the medical record.


  • Collaborates with case managers, nursing staff, Physician Validator and other ancillary staff regarding interaction with physicians on documentation and to resolve physician queries prior to patient discharge.


  • Participates in the analysis and trending of statistical data for specified patient populations to identify opportunities for improvement.


  • Reviews external (i.e. PEPPER) and internal data (i.e. outliers) to trend, track and educate to improve outcomes.


  • Assists with preparation and presentation of clinical documentation monitoring/trending reports for review with physicians and hospital leadership.


  • Educates members of the patient care team regarding specific documentation needs and reporting and reimbursement issues identified through daily and retrospective documentation reviews and aggregate data analysis.


  • Instructs staff on best practices to ensure accurate documentation in the medical record.




  • Maintains and reports clinical documentation improvement results in a clear and concise manner to the medical, clinical, and management staff.


  • Applies diplomacy and professionalism when interacting with  physicians and clinical staff; especially when addressing missing or conflicting medical record information


  • Works in partnership with an interdisciplinary team to foster collaboration, learning and accurate and complete medical record documentation.


  • Exhibits skillful, up to date working knowledge of all coding guidelines (Federal and State, etc...) researching websites, publications, and reference materials. Adheres to coding policies and guideline published in “Coding Clinic” and HIM department policies and procedures.


  • Collaborates with HIM coding staff, physicians and finance to reduce payment denials, and improve medical necessity documentation.


  • Acts as a consultant to providers, management, administration and billing staff with regard to documentation, coding, and reimbursement and compliance matters.


  • Investigates, evaluates and identifies opportunities for improvement and recognizes their relative significance in the overall system.


  • Provides orientation for new clinical staff with regard to documentation requirements and coding/billing issues as required.


  • Assists in coordinating responses to third party payer audits and/or requests when appropriate; determine the appropriate documentation to be submitted, and formulate responses.


  • Keeps current with coding scheme changes, proposed and otherwise, through conferences, reference material and review of current literature.


  • Maintains confidentiality of all customer/hospital information.


  • Demonstrates flexibility in the face of changing work environment, adjusting work schedule accordingly.



  • Participate in departmental and/or interdepartmental quality improvement activities. 
  • Participate in and successfully completes Mandatory Education.
  • Perform all other duties as needed or directed to meet the needs of the department.



40 Hours Weekly

About Us

Beth Israel Lahey Health is dedicated to improving health and wellness and making a difference in the lives of our patients, their families and all members of the communities we serve.  Formed in March 2019, Beth Israel Lahey Health is a patient-centered, integrated care delivery system providing a continuum of services spanning academic, tertiary and community hospitals, dedicated orthopedic and psychiatric hospitals, primary and specialty care, community acute care, ambulatory care, behavioral services and home health.  Beth Israel Lahey Health Performance Network is a unified joint contracting and population health management organization, jointly governed by participating physicians and hospitals.

Equal Opportunity Employer/Minorities/Females/Disabled/Veterans.