Job Description

**Summary:**

The Clinical Documentation Specialist - Retrospective reviewer, collaborates with coding compliance and the department of healthcare quality in retrospective review of qualified selected cases. The employee as a acts as a liaison between medical staff, Nursing, Coding and QI specialist to ensure the clinical documentation supports and reflects the most appropriate level of services and resources provided.

**Current States eligible for remote: CT, FL, MD, NH, NC, OH, RI, TN, TX, VT, VA, MA, PA**

**Job Responsibilities:**

**1)** Provides clinically based retrospective review of inpatient medical records to assess and procure accurate and complete documentation of the patients' diagnoses and procedures.

**2)** Ensures documentation accurately reflects quality of care, severity of illness and risk of mortality to support correct coding, reimbursement and quality initiatives.

**3)** Contacts physicians or other departments regarding procedures/diagnoses to ensure proper documentation.

**4)** Identifies opportunities to improve documentation and coding workflow process. Collaborates with the HIM management and staff.

**5)** Prepares and presents educational sessions to physicians on proper documentation.

**6)** Monitors and participates in performance improvement initiatives.

**7)** Participates in the planning for assigned inter/intra departmental meetings and presentations.

**8)** Participates in professional development and activities to keep current with trends in coding. This can include offsite meetings/conferences/site visits where travel and overnight stay might be required.

**9)** Communicates effectively and adaptable to a wide variety of interpersonal environments within the entire healthcare system. Able to be an approachable liaison to facilitate the achievement of CDI goals.

**10)** All tasks need to be performed following the Operating Principles of Baystate Health. Adheres to system and department compliance policies, and any and all applicable laws and regulations.

**Education:**

Associates degree or higher, graduate of a nursing or physician training program.

**Required Work Experience:**

**1)** Must have a minimum of 3 years of CDI experience; 5 years preferred

**2)** May consider Physician Trained experience

**Preferred Work Experience:**

**1)** Familiar with CIS, MS Office

**Skills and Competencies:**

**1)** Extensive clinical knowledge and understanding of pathology/physiology; best demonstrated by clinical experience in hospital setting

**You Belong At Baystate**

At Baystate Health we know that treating one another with dignity and equity is what elevates respect for our patients and staff. It makes us not just an organization, but also a community where you belong. It is how we advance the care and enhance the lives of all people.

DIVERSE TEAMS. DIVERSE PATIENTS. DIVERSE LOCATIONS.

**Education:**

Diploma in Nursing: Anatomy (Required)

**Certifications:**

Certified Clinical Documentation Special - Other, Certified Coding Specialist - American Health Information Management Association, Registered Health Information Associate - American Health Information Management Association, Registered Health Information Technician - American Health Information Management Association, Registered Nurse - State of Massachusetts

**Equal Employment Opportunity Employer**

Baystate Health is an Equal Opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, marital status, national origin, ancestry, age, genetic information, disability, or protected veteran status.

**Ab** **out Baystate Health**

Baystate Health (BH) is one of New Englands leading and largest integrated health care organizations, serving a population of nearly one million people throughout western New England. With roots dating back to the founding of Springfield City Hospital in 1873, Baystate Health has been providing high-quality and compassionate health care in western Massachusetts for more than 145 years. With more than 12,000 employees, a medical staff of nearly 3,100 physicians, and a net patient service revenue of more than $1.4 billion, the ever-growing health system includes five Massachusetts hospitals and the Baystate Mary Lane Outpatient Center in Ware:

+ Baystate Medical Center in Springfield

+ Baystate Childrens Hospital (located at Baystate Medical Center)

+ Baystate Franklin Medical Center in Greenfield

+ Baystate Wing Hospital in Palmer

+ Baystate Noble Hospital in Westfield

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