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Clinical Documentation Specialist I – CDI
Beth Israel Lahey HealthClinical Documentation Specialist I focused on accurate diagnoses and quality data in patient records. Collaborating with healthcare teams to drive documentation improvement in inpatient care.
ATS Keywords
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Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
query writingchart auditsdocumentation improvementclinical validationDRG assignmentpatient data accuracymedical record documentationnursing experiencecritical care nursingemergency nursing
Soft Skills
organizational skillscritical thinkingcommunicationcollaborationeducation
Tools & Technologies
web-based applicationsMicrosoft OfficeOutlookWordExcelPowerPointAccess
Certifications & Qualifications
RN LicenseBachelor’s in Nursing
Industry Keywords
acute hospital settinginpatient recordsdocumentation guidelinespatient care teamphysician documentation
About the role
Key responsibilities & impact- Assists with the appropriate identification of diagnoses, conditions, and/or procedures that are representative of the patient’s hospital stay and care provided
- Initiates concurrent queries to providers as supported by medical record documentation to improve the accuracy, integrity, and quality of patient data
- Reviews inpatient records to ensure completeness, accuracy, and clinical validation
- Evaluates documentation for assignment of working and possible DRG
- Recognizes opportunities for documentation improvement
- Identifies opportunities to query physicians regarding missing, unclear, or conflicting documentation
- Interacts directly with physicians to request and obtain additional documentation when needed
- Facilitates modifications to physician documentation to reflect the complexity of care of the patient
- Collaborates with and educates members of the patient care team regarding documentation guidelines
Requirements
What you’ll need- Bachelor’s in Nursing, required
- RN License
- 1-2 years of medical/surgical nursing experience in the acute hospital setting
- Critical Care and/or Emergency Nursing experience required
- Proficient skill in query writing to physicians
- Knowledge to accurately complete chart audits
- Organizational and critical thinking skills required
- Experience with computer systems required, including web-based applications and some Microsoft Office applications which may include Outlook, Word, Excel, PowerPoint, or Access
Benefits
Comp & perks- Health insurance
- Paid time off
- Flexible working hours
- Professional development opportunities