Clinical Documentation Specialist

2 months ago


Newton, United States Mass General Brigham Full time
Job Title: Clinical Documentation Specialist

Mass General Brigham is seeking a skilled Clinical Documentation Specialist to join our team. As a Clinical Documentation Specialist, you will play a critical role in ensuring the accuracy and completeness of medical records, facilitating compliance with regulatory requirements, and supporting the delivery of high-quality patient care.

Key Responsibilities:
  • Conduct concurrent medical record reviews to identify documentation gaps and opportunities for improvement.
  • Review physician documentation to ensure accuracy and completeness, and identify areas for improvement.
  • Collaborate with physicians, coding staff, and other healthcare professionals to resolve documentation issues and improve coding accuracy.
  • Develop and implement strategies to improve documentation quality and reduce coding errors.
  • Stay up-to-date with regulatory requirements and industry developments to ensure compliance and best practices.
Requirements:
  • Bachelor's degree in Nursing or related field.
  • Minimum 5 years of experience in acute med-surg or critical care nursing.
  • 3-5 years of experience in clinical documentation or coding.
  • Knowledge of Medicare, federal, and state healthcare regulations and related accreditation requirements.
  • Ability to communicate effectively with physicians, coding staff, and other healthcare professionals.
Preferred Qualifications:
  • Clinical Documentation Specialist certification.
  • Experience with coding/classification systems for inpatient DRG prospective payment system.

Mass General Brigham is an equal opportunity employer and welcomes applications from diverse candidates. We offer a competitive salary and benefits package, as well as opportunities for professional growth and development.



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