Clinical Documentation Specialist

About the role

As a Clinical Documentation Specialist at Quincy Medical Group, you will play a key role in advancing our Value-Based Care initiatives by partnering with providers to improve clinical documentation, diagnosis capture, and coding accuracy.

Responsibilities

• Partner with providers to improve clinical documentation, diagnosis capture, and coding accuracy.
• Provide education and training on documentation best practices, risk adjustment principles, and applicable coding guidelines.
• Review medical record documentation to identify opportunities for improved specificity, completeness, and accurate diagnosis capture.
• Analyze documentation trends, audit findings, and performance metrics to develop targeted provider education.
• Serve as a subject matter expert on documentation integrity, regulatory requirements, and clinical documentation improvement initiatives.
• Collaborate with coding, quality, operations, and clinical leadership teams to support organizational goals.
• Develop educational resources, job aids, and reference materials that support provider success.
• Maintain current knowledge of CMS guidance, ICD-10, HCC risk adjustment, and industry best practices.
• Support ongoing quality improvement initiatives and process enhancement efforts.
• Build collaborative relationships with providers, clinic leadership, and interdisciplinary teams.
• Perform other duties as assigned to support Value-Based Care initiatives.

Qualifications

• Bachelor's degree in nursing, health information management, healthcare administration, or a related field preferred.
• Current RN license or comparable clinical background preferred.
• Certified Professional Coder (CPC), Certified Risk Adjustment Coder (CRC), or ability to obtain certification within six months of hire preferred.
• Minimum of two years of experience in clinical documentation improvement, risk adjustment, coding, quality, population health, or a related healthcare field preferred.
• Working knowledge of ICD-10 coding, CMS documentation requirements, and risk adjustment principles preferred.
• Strong analytical, critical thinking, and problem-solving skills.
• Excellent presentation, communication, and relationship-building abilities.
• Ability to educate and influence providers through collaborative coaching and feedback.
• Strong organizational skills with the ability to manage multiple priorities independently.
• Proficiency with electronic medical records and Microsoft Office applications.

Benefits

• Comprehensive medical, dental, and vision benefits that include healthcare navigation assistance.
• Access to a mental health benefit at no cost.
• Employer provided life and disability insurance.
• $5,250 Tuition Reimbursement per year.
• Immediate 401(k) match.
• Flexible time off.
• 40 hours paid volunteer time off.
• A culture committed to community engagement and social impact.
• Up to 12 weeks parental leave at 100% pay and a financial benefit for adoption and surrogacy for non-physician team members once eligibility requirements are met.

Pay

The compensation for this role includes a base pay range of $63,211.20 - $94,827.20 annually, with actual pay determined by experience, education, certifications, geographic location, and internal equity. Additional compensation may be available through bonuses and other incentives.

Schedule & Work Environment

Full-time position, Monday - Friday, daytime hours. Schedule flexibility may be necessary to accommodate provider education sessions and organizational initiatives. Collaborative environment supporting providers across multiple specialties.