Clinical Documentation Specialist

18 hours ago


Milford, Massachusetts, United States Milford Fire Department - Massachusetts Full time
Job Title: Clinical Documentation Improvement Specialist

Milford Regional Medical Center is seeking a skilled Clinical Documentation Improvement Specialist to join our team.

Job Summary:

The Clinical Documentation Improvement Specialist is responsible for reviewing medical records for technical accuracy, specificity, and completeness of provider clinical documentation. This role involves collaborating with healthcare team members to improve documentation and ensure accurate, comprehensive records.

Key Responsibilities:
  • Review medical records for technical accuracy and completeness
  • Initiate and complete query process to ensure complete documentation
  • Collaborate with providers and healthcare team members to improve documentation
  • Ensure accurate, comprehensive records that reflect clinical treatment, decisions, and diagnoses
Qualifications:
  • Bachelor of Science in Nursing preferred or equivalent combination of education/experience
  • CCDS or CDIP certification required; ability to obtain within 2 years
  • Registered Health Information Administrator/Registered Health Information Technologist (RHIA/RHIT) or Certified Coding Specialist
  • Minimum 5 years clinical expertise and extensive knowledge of complex disease processes
Working Conditions:

This role requires working in a fast-paced healthcare environment with a focus on quality improvement and patient care.

Milford Regional Medical Center is a full-service, community and regional teaching hospital located in Milford, Mass. and serves patients from more than 20 towns in Central Massachusetts.



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