Clinical Documentation Specialist

7 days ago


Newton, United States Mass General Brigham Full time
Job Summary

Mass General Brigham is seeking a highly skilled Clinical Documentation Specialist to join our team. As a key member of our healthcare team, 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.
  • Collaborate with physicians and healthcare staff to obtain accurate and complete documentation.
  • Develop and implement strategies to improve documentation quality and compliance with regulatory requirements.
  • Provide education and training to healthcare staff on documentation best practices and regulatory requirements.
  • 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 staff and physicians.
Preferred Qualifications
  • Clinical Documentation Specialist certification.
  • Experience with coding/classification systems for inpatient DRG prospective payment systems.
What We Offer

Mass General Brigham offers a competitive salary and benefits package, as well as opportunities for professional growth and development.



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