Concurrent Clinical Documentation Integrity (CDI) Specialist

Hours: 40 hours per week; Monday through Friday

Location: Remote

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.   An entry level role that applies broad theoretical job knowledge typically obtained through advanced education.  May require the following proficiency:  work is closely supervised, problems faced are not typically difficult or complex, and explains facts, policies and practices related to job area.

Job Overview

This position is responsible for enhancing the quality, accuracy, completeness, and integrity of clinical documentation within the medical record. This position ensures that documentation accurately reflects the patient's severity of illness, risk of mortality, diagnoses, procedures, and services provided. This position is responsible for conducting high volume, concurrent reviews of inpatient medical records to identify opportunities for improved clinical documentation accuracy, complements, and specificity.  This position functions as a part of specialized production team designed to maximize review capacity through focused clinical review activities.  Responsibilities in this role do not include physician query follow up, physician or provider outreach, query escalation, query reconciliation, CDI/Coding reconciliation as those functions will be performed by a dedicated team in those areas. Through comprehensive review of clinical records, this position identifies documentation opportunities, facilitates compliant clinical documentation clarification, and supports accurate coding, quality reporting, reimbursement, and regulatory compliance. This role is critical in ensuring the medical record accurately represents the patient's clinical condition while supporting organizational performance related to quality outcomes, case mix index, and reimbursement. This position requires the ability to consistently perform in a high production environment while maintaining exceptional quality standards. Incumbents are expected to meet established productivity goals and maintain a minim quality review score of 95% as measured through departmental quality audits and performance evaluations.

Job Description

Minimum Qualifications:

1. Associate’s degree in related healthcare field (ie, medical coding and billing programs, nursing programs, healthcare admin).

2. One (1) year of Clinical Documentation Integrity (CDI) experience in an acute care setting; OR One (1) year of acute care clinical experience (ICU, Emergency Department, Critical Care, or Medical-Surgical specialties), case management, utilization review, or denials management.

3. Active, unrestricted Registered Nurse (RN) license in Massachusetts; OR a Nurse Licensure Compact (NLC) state; OR AHIMA Certified Coding Specialist (CCS) credential; OR AAPC Certified Inpatient Coder (CIC).

Preferred Qualifications:

1. Bachelor’s degree in nursing (BSN) or Registered Health Information Administrator (RHIA) credential.

2. Two (2) years of Clinical Documentation Integrity (CDI) experience in an acute care setting.

3. Certified Clinical Documentation Specialist (CCDS) and/or Clinical Documentation Improvement Practitioner (CDIP) certification.

Duties and 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. Performs initial and subsequent concurrent reviews of electronic medical record to identify documentation opportunities, while consistently achieving established concurrent review volume goals and maintaining quality and accuracy standards.

2. Evaluates the medical record for completeness, consistency, precision and clarity.

3. Identifies query opportunities for provider clarification. Record and issue compliant, clinically supported queries in accordance with organizational policies and industry guidelines.

4. Exercise professional judgment to determine when provider queries are warranted and when existing documentation sufficiently supports accurate code assignment, avoiding unnecessary or non-compliant queries.

5. Maintains alignment with coding professionals by staying current with coding guidelines.

6. Accurately and thoroughly documents reviews and other pertinent information in designated systems in compliance with established policies, procedures, and documentation standards.

7. Exhibits strong critical thinking skills and medical knowledge of disease processes with an exceptional ability to integrate knowledge.

8. Responsible for effective time management and efficient prioritization to achieve and maintain key operating metrics consistent with CDI Department needs and requirements.

9. Independently takes proactive steps toward problem solving, conflict resolution, and troubleshooting of technology errors.

Physical Requirements:

1. Professional office environment with typical office requirements such as computers, phones, photocopiers, filing cabinets, etc.

2. This is largely a sedentary role, which involves sitting most of the time, but may involve movements such as walking, standing, reaching, ascending / descending stairs, and operate office equipment.

3. Frequently required to speak, hear, communicate, and exchange information.

4. Able to see and read computer displays, read fine print, and/or normal type size print and distinguish letters, numbers, and symbols.

5. Occasionally lift and/or move up to 25 pounds.

Skills & Abilities:

1. Ability to read and write in the English language. Ability to understand and speak English fluently enough to be easily understood by patients, hospital personnel, physicians, and visitors.

2. Strong critical thinking skills and sound clinical background with a working knowledge of disease processes, anatomy and physiology, and treatment regimens.

3. Ability to analyze and interpret clinical information in the patient’s medical record.

4. Excellent verbal and written communication skills with strong attention to detail and accuracy.

6. Knowledge of ICD-10, AHIMA and Coding Guidelines, healthcare regulations, reimbursement, and documentation requirements.

8. Open, flexible, and adaptable to a changing environment as the CDI industry continues to change and evolve.

9. High level Computer literacy and efficiency with technology, including but not limited to, Microsoft Office Suite (including Word, Excel, Teams), Zoom, Epic, 3M360.    

10. Ability to use good judgment in an emergency situation. 

At Tufts Medicine, we want every individual to feel valued for the skills and experience they bring. Our compensation philosophy is designed to offer fair, competitive pay that attracts, retains, and motivates highly talented individuals, while rewarding the important work you do every day.

The base pay ranges reflect the minimum qualifications for the role. Individual offers are determined using a comprehensive approach that considers relevant experience, certifications, education, skills, and internal equity to ensure compensation is fair, consistent, and aligned with our business goals.

Beyond base pay, Tufts Medicine provides a comprehensive Total Rewards package that supports your health, financial security, and career growth—one of the many ways we invest in you so you can thrive both at work and outside of it.

Pay Range:

based on full-time equivalent