Clinical Documentation Specialist III

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 concurrent and retrospect 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. Contributes to CDI and documentation initiatives related to provider engagement, relationship establishment and maintenance, provider education, including formal and informal education plans, as well as participates in department and organization projects related to documentation improvement. The position is a Subject Matter Expert also responsible for initiating special CDI projects for process improvement and participates in hospital meetings such as UR, Case Management, Quality, and meetings with Physician Advisors/Champions.

Job Description

Minimum Qualifications:

1. Bachelor’s Degree in Nursing 
2. Active Registered Nurse (RN) license in Massachusetts or compact state
3. Three (3) years’ experience in an acute-care hospital setting (ICU, ED, Critical Care, strong Med/Surg Specialty) or equivalent case management, utilization review, denials management, or progressive leadership in an acute-care hospital setting
4. Three (3) 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
7. Master’s Degree in Nursing, Healthcare Management, Healthcare Administration, Business Administration, or other related field

Preferred Qualifications:

2. Ccs Certification

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. 1. Demonstrates knowledge of Official Guidelines for Coding and Reporting, APR-DRG and MS-DRG Classification System to ensure industry best practice standards and regulatory compliance related to the CDI and coding functions.
2. 2. 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.
3. Performs retrospective review of discharged encounters, accurately identifies discrepancies in documentation, and facilitates timeliness of appropriate documentation or coding modifications.
4. 4. Demonstrates a strong understanding of case mix index, MCC/CC capture, severity of illness/risk of mortality, LOS, risk adjustment diagnoses.
5. Provide 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.
6. 6. Serves as a resource and mentor to CDS I and CDS II team members.
7. 7. Assist in quality audits of CDS I and CDS II team members. Identify the need for additional training and resources needed for the success of the CDI Team.
8. 8. Demonstrates ability to analyze CDI data and prepare presentations for education and insight into CDI trends and outcomes.
9. 9. Works closely with the Quality team to identify and ensure that the provider documentation is complete to address PSIs, HACs, Mortality, and Vizient variables, as well as other Quality indicators where indicated.
10. 10. Collaborates with case management and utilization review team to ensure that documentation is clearly substantiated in the record to prevent denials as appropriate as well as to provide clear documentation for level of care.

Physical Requirements:

Skills & Abilities:

Job Profile Summary

​This role focuses on activities related to revenue cycle operations such as billing, collections, and payment processing.  In addition, this role focuses on performing the following CDI related duties: Facilitates improvement in overall quality, completeness, and accuracy of medical record documentation, obtains appropriate clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, and coding staff to ensure that documentation reflects the level of service rendered to patients is complete and accurate, and serves as a resource to all team members on documentation guidelines, provides guidance and support as well as assisting in the education and training related to improving clinical documentation.  A professional individual contributor role that may direct the work of other lower level professionals or manage processes and programs.  The majority of time is spent overseeing the design, implementation or delivery of processes, programs and policies using specialized knowledge and skills typically acquired through advanced education.   A senior level role that requires advanced knowledge of job area typically obtained through advanced education and work experience.  Typically responsible for: managing projects / processes, working independently with limited supervision, coaching and reviewing the work of lower level professionals, resolving difficult and sometimes complex problems.