**Job Type:** Regular **Time Type:** Full time **Work Shift:** Day (United States of America) **FLSA Status:** Exempt **When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives.** The Clinical Documentation Improvement Specialist (CDS) assists with 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 Mortality (ROM), during an inpatient hospitalization. CDS 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 CDS works under direction of the Manager of CDI and collaborates with coding, clinicians, medical staff, and physician advisors to improve documentation and importance of complete and accurate documentation. **Job Description:** **Essential Duties & Responsibilities including but not limited to:** 1. 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 software. 2. Conducts follow-up reviews of patients every 2 days to support and assign a working DRG assignment. 3. Queries physicians regarding missing, unclear, or conflicting medical record documentation by requesting and obtaining additional documentation within the medical record when needed. 4. Educates physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the medical record. 5. Collaborates with the CDI Manager & Physician Advisor and other ancillary staff regarding interaction with physicians on documentation and to resolve physician queries prior to patient discharge. 6. Educates members of the patient care team regarding documentation opportunities and best practices to ensure accurate documentation in the medical record. 7. Applies diplomacy and professionalism when interacting with physicians and clinicians; especially when addressing missing or conflicting medical record information 8. Works in partnership with an interdisciplinary team to foster collaboration, learning and accurate and complete medical record documentation. 9. Exhibits working knowledge of inpatient coding guidelines. Adheres to CDI convention and department policies and procedures. 10. Investigates, evaluates, and identifies opportunities for improvement and recognizes their relative significance in the overall system. 11. Provides orientation for new clinical staff regarding documentation requirements as required. 12. Keeps current with CDI concepts and practices through conferences, reference material and review of current literature. 13. Maintains confidentiality of all customer/hospital information. 14. Demonstrates flexibility in the face of changing work environment, adjusting work schedule accordingly. **Minimum Qualifications:** Education: Degree in Nursing, Bachelor’s preferred, or comparable education as Medical School graduate. Related Master’s Degree highly desirable. Licensure, Certification & Registration: Current active RN licensure or for Medical School graduate: Required certification from Educational Commission for Foreign Medical Graduates (ECFMG). Certified CDIP, CCDS, CCS highly desirable. Experience: Must have at least 5 years acute care hospital level nursing experience (e.g., medical-surgical, ICU) or equivalent case management, quality, or utilization review in a hospital setting Skills, Knowledge, and Abilities + Positive & professional communication skills + High level Computer literacy required: applicable to EMR entry & software program proficiency for CDI workflow. **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. Beth Israel Lahey Health requires that all staff be vaccinated against influenza (flu) and COVID-19 as a condition of employment. Learn more (https://www.bilh.org/newsroom/bilh-to-require-covid-19-influenza-vaccines-for-all-clinicians-staff-by-oct-31) about this requirement.** **More than 35,000 people working together. Nurses, doctors, technicians, therapists, researchers, teachers and more, making a difference in patients' lives. Your skill and compassion can make us even stronger.** **Equal Opportunity** **Employer/Veterans/Disabled**