Clinical Documentation Specialist

3 hours ago


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

Mass General Brigham is seeking a highly 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 promoting 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 communicate with physicians to resolve discrepancies.
  • Develop and implement strategies to improve documentation quality and reduce errors.
  • Collaborate with healthcare teams to ensure accurate and timely documentation of patient care.
  • Monitor and evaluate the effectiveness of documentation improvement initiatives.
Requirements:
  • Bachelor's degree in Nursing or related field.
  • Minimum 5 years of experience in acute medical-surgical 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 healthcare teams and physicians.
Preferred Qualifications:
  • Certification as a Clinical Documentation Specialist.
  • Knowledge of coding/classification systems for inpatient DRG prospective payment system.
What We Offer:
  • A dynamic and supportive work environment.
  • Opportunities for professional growth and development.
  • A competitive salary and benefits package.


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