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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.
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
ATS Keywords
✓ Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
query writingchart auditsdocumentation improvementclinical validationDRG assignmentpatient data accuracymedical record documentationnursing experiencecritical care nursingemergency nursing
Soft Skills
organizational skillscritical thinkingcommunicationcollaborationeducation
Certifications
RN LicenseBachelor’s in Nursing