Job Description

Location: Steward Health Care
Posted Date: 10/27/2020

Position Summary

The Emergency Department Clinical Documentation Integrity Specialist shall support a designated hospital within the North East Division and be based within the Emergency Department. The position shall support providers with clinical documentation integrity efforts and level of care decision support.

This includes adherence to Emergency Room documentation best practices such as capture of all clinically relevant aspects of the patient encounter including laboratory, radiologic, and other test results. Ensure the Emergency Room medical record accurately captures the process of evaluation, management, medical decision making, and medications, past history, disposition, and clinical assessment and/or diagnoses. Efforts shall include education on more specific or specified conditions versus those sign/symptom or unspecified conditions.

The position shall utilize criteria to confirm medical necessity for appropriate level of care settings. The Emergency Department Clinical Documentation Integrity Specialist shall provide education to providers on areas of documentation opportunities.

Key Responsibilities

  • Review of Emergency Room medical records
  • Provide documentation integrity support to Emergency Room providers
  • Identify high risk patients of incorrect level of care utilizing specific criteria
  • Conduct real-time admission reviews based on appropriate utilization criteria established by standards, procedures, and/or polices
  • Perform real-time professional education to providers
  • Knowledgeable with Steward Health Care Emergency Room Evaluation and Management (E&M) guidelines
  • Track common areas of missed documentation for department and/or organizational education
  • Ensure appropriate level of care is documented by the attending physician
  • Support hospital Case Management, Health Information Management, and Clinical Documentation departments
  • Elevate complex cases to the Director of Case Management and/or Physician Advisor
  • Present findings to CDI and CM Leadership monthly

Required Knowledge and Skills

  • Comprehensive understanding of ICD-10-CM, CCs/MCCs, UHDDS guidelines, and HACs and PSIs
  • Comprehensive understanding of Inpatient Admission Criteria, 2 Midnight Rule, InterQual, and Milliman
  • Meditech experience required
  • Microsoft Office (Word, One Note, Excel, Outlook, PowerPoint)
  • Excellent verbal and written communication skills
  • Ability to meet assigned deadlines
  • Ability to serve as a knowledge expect for providers
  • Ability to work independently


  1. Education: Associates or bachelor’s degree required
  2. Experience: +2 years of Acute Care CDI experience;
  3. Certification/Licensure: Registered Nurse (RN) required
  4. Software/Hardware: Iodine and 3M experienced preferred
  5. Other: Required to work at a designed hospital during peak admission times

Application Instructions

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