Clinical Documentation Specialist I / II

Location: 100% Remote

Certification and experience required for this role

About Tufts Medicine:

Tufts Medicine is a leading integrated health system bringing together the best of academic and community healthcare to deliver exceptional, connected and accessible care experiences to consumers across Massachusetts. The health system is the principal teaching affiliate for Tufts University School of Medicine. The strong relationship between Tufts Medicine and Tufts University School of Medicine is evident in our governance, academic and research structure. Tufts Medicine is comprised of the following clinical entities:

·       Tufts Medicine Professional Group (TMPG)

·       Tufts Medicine Integrated Network (TMIN)

·       Tufts Medical Center

·       Lowell General Hospital

·       MelroseWakefield Hospital, Lawrence Memorial Hospital of Medford

·       Tufts Care at Home

Job Overview 

The position is responsible for review and analysis of the medical record to improve overall quality and completeness of clinical documentation. The position facilitates and obtains appropriate modifications to clinical documentation, including clinical conditions and procedures, for accurate representation of severity of illness, expected risk of mortality, and complexity of care of the patient through extensive interaction with physicians, HIM professionals, and other interdisciplinary team members.

Job Description ​

Minimum Qualifications for CDI level I:

1. Associate’s degree in Nursing 

2. Active Registered Nurse (RN) license in Massachusetts or compact state

3. Five (5) years’ experience in an acute-care hospital setting (ICU, ED, Critical Care, strong Med/Surg Specialty) OR case management, utilization review, or denials management in an acute-care hospital setting

Minimum Qualifications for CDI level II:

1. Bachelor’s Degree in Nursing 

2. Active Registered Nurse (RN) license in Massachusetts or compact state

3. Five (5) years’ experience in an acute-care hospital setting (ICU, ED, Critical Care, strong Med/Surg Specialty) OR case management, utilization review, or denials management in an acute-care hospital setting

4. Two (2) years’ experience in Clinical Documentation Improvement/Integrity

5. Advanced clinical expertise and extensive knowledge of complex disease processes with broad clinical experience is required.

6. CCDS and/or CDIP Certification

Preferred Qualifications:

1. Bachelor’s degree in nursing

Duties & Responsibilities: The duties and responsibilities listed below are intended to describe the general nature of work and are not intended to be an all-inclusive list.  Other duties and responsibilities may be assigned. 

1. Performs initial concurrent review of new patients every day and concurrent re-reviews approximately every two days until the patient is discharged except weekends and company-approved holidays.

2. Evaluates the medical record for completeness, consistency, precision, clarity, and legibility. Aligns with the coding professionals by maintaining knowledge of the current Coding Guidelines, ongoing communication, and serving as a liaison between physicians and coders.

3. Thoroughly documents reviews, query follow up, and other pertinent information in designated systems by established deadlines.

4. Exhibits strong critical thinking skills and medical knowledge of disease processes with an exceptional ability to integrate knowledge. Ability to analyze complex clinical information to identify areas within the medical record for potential gaps in physician documentation.

5. Identifies opportunities and provide rationale with supported clinical criteria such as pathology of disease processes, diagnostic findings, lab values, and signs/symptoms and/or coding guidelines when applicable and forward such discrepancies to management staff in a timely manner for resolution.

6. Provides relevant feedback and compliant, clinically credible clarifications with the ability to communicate clearly, proactively, and concisely when interacting with physicians.

7. Provides education to physicians and other members of the patient care team to ensure their understanding of the clarification process and the desired outcome of documentation excellence for severity of illness and intensity of care. Provides feedback and education in proficient verbal and written formats both remotely and onsite.

8. Simultaneo