At Boston Children's Hospital, success is measured in patients treated, parents comforted and teams taught. It's in discoveries made, processes perfected, and technology advanced. In major medical breakthroughs and small acts of kindness. And in colleagues who have your back and patients who have your heart. As a teaching hospital of Harvard Medical School, our reach is global and our impact is profound. Join our acclaimed Clinical Documentation Integrity (CDI) Program and discover how your talents can change lives. Yours included.

This Clinical Documentation Integrity Specialist will be responsible for:

• Facilitating appropriate clinical documentation to support appropriate diagnosis coding and to ensure the level of service rendered to all patients is accurately reflected.
• Collaborating with HIM coding staff to promote complete and accurate clinical documentation and correct negative trends.
• Communicating with physicians, nurse practitioners, case managers, coders and other members of the care team to facilitate comprehensive medical record documentation to reflect treatment, decision-making and medical documentation.
• Assigning a working APR-DRG, severity of illness and risk of mortality using coding rules and guidelines.
• Analyzing clinical information to identify areas within the chart for potential gaps in physician documentation.
• Query physicians on a concurrent basis. Work with clinicians to clarify documentation in the medical record.
• Formulating credible clinical documentation clarifications to improve clinical documentation of principal diagnosis, co-morbidities, present on admission (POA), quality core measures, and patient safety indicators (PSI).
• Conducting post discharge reviews for comparative analysis of CDI Specialist and HIM APR-DRG, adding SOI and ROM assignments. Reviewing clinical issues with the coding staff to assign a working DRG.
• Developing and conducting ongoing education for new staff, including new CDI Specialists, physicians and nursing.
• Utilizing software systems (including APR-DRG encoder) to collect, track, and report outcomes. Being proficient in abstraction of data and entry into all databases used for clinical documentation. Maintaining integrity of data collection.
• Participating in ongoing education of staff. Developing educational materials and tools relative to documentation improvement practices for individual practitioners and groups of clinicians presented as handouts, PowerPoint, etc.

• A Bachelor's Degree (Nursing strongly preferred)
• If no nursing background, certification as an inpatient coder or other relevant clinical experience (e.g. MD-equivalent degree) required
• Clinical inpatient hospital experience preferred.
• Experience as a CDI Specialist in an inpatient setting, preferred.
• Superior communication & interpersonal skills; demonstrated ability to communicate effectively with clinicians.
• Competency in MS Office; experience with Cerner EMR preferred.
• Working knowledge of the APR-DRG and ICD10 coding strongly preferred.