Clinical Documentation Specialist

Schedule: Full Time Pay Range: $37.00 - $73.00 / Hourly Shift: Day shift Hours: 7a-3:30p About This Role Improve Patient Care. Strengthen Documentation. Drive Impact. About The Role We're seeking a detail-oriented and collaborative Clinical Documentation Specialist (CDS) to join our Medical Records team. In this role, you will help ensure the accuracy, completeness, and integrity of clinical documentation-supporting high-quality patient care, regulatory compliance, and appropriate reimbursement. Reporting to the Manager, Clinical Documentation & Coding, you will work closely with physicians, nurses, and interdisciplinary teams to ensure documentation reflects the full clinical picture. In this role, you will perform concurrent reviews of inpatient medical records to identify documentation gaps and opportunities to enhance the quality and accuracy of physician documentation. If you thrive in a fast-paced clinical environment and enjoy combining clinical expertise with problem-solving and collaboration, this is a great opportunity to make a meaningful impact. What You'll Do Review medical records to ensure accurate, complete, and compliant clinical documentationCollaborate with physicians and care teams to clarify and improve documentation qualityApply clinical and coding knowledge to support accurate code assignment and reimbursementFacilitate documentation improvement initiatives in both concurrent and retrospective reviewsEducate providers and care teams on CMS regulations, documentation standards, and best practicesPartner with coding professionals to ensure alignment between documentation and coding outcomesSupport quality, compliance, and continuous improvement initiatives across the organization What You Bring Education Bachelor of Science in Nursing (BSN) or Bachelor of Science in Biology or a related healthcare clinical program (e.g., Medical Records/Health Information Management) Experience One of the following:3-5 years of acute care or equivalent clinical experience, or3+ years of inpatient coding experience Licensure & Certification Current Massachusetts Registered Nurse (RN) license and/orAHIMA coding certification (e.g., CCS, RHIT, RHIA) required Skills & Competencies Ability to work independently and manage responsibilities with minimal supervisionStrong verbal and written communication skillsProven ability to build effective working relationships with a wide range of healthcare providersTeam-oriented mindset with strong collaboration and information-sharing skillsCritical thinking and problem-solving abilities in complex clinical scenariosStrong organizational skills with the ability to stay focused despite frequent interruptionsProficiency with computer systems and ability to quickly learn new software applicationsEffective time management skills, with the ability to prioritize multiple tasks and meet deadlinesAbility to interpret medical record documentation, prepare reports, and communicate findings clearlyComfort working with basic mathematical concepts such as percentages, ratios, and data analysisKnowledge of DPH regulations, Medicare/CMS rules and regulationsUnderstanding of Joint Commission standards and continuous quality improvement (CQI) processesCommitment to maintaining strict confidentiality of patient and organizational information Why Join Us? Make a direct impact on patient care quality and outcomesCollaborate with a dedicated, interdisciplinary healthcare teamExpand your expertise in clinical documentation, compliance, and healthcare qualityCompetitive compensation and comprehensive benefits To apply, please visit: https://emersonhealth.org/jobs/clinical-documentation-specialist-34934/? Copyright ©2025 Jobelephant.com Inc. All rights reserved. Posted by the FREE value-added recruitment advertising agency je-b3da4e899a54429bbbdc22d2fddcb85d