[Hiring] Clinical Documentation Specialist @Mass General Brigham

Role Description

We are seeking a per diem Clinical Documentation Specialist to join the Utilization Management department supporting Mass General Brigham Home Care. The Clinical Documentation Improvement (CDI) Specialist is responsible for enhancing the accuracy, completeness, and quality of clinical documentation to support appropriate reimbursement, quality care initiatives, and compliance with regulatory requirements.

• Review patient medical records to ensure clinical documentation is accurate, complete, and compliant with established documentation standards.
• Collaborate with physicians, nurses, and other healthcare professionals to clarify documentation and obtain information necessary to support accurate coding and billing.
• Provide guidance to coding staff on documentation requirements that support accurate code assignment, regulatory compliance, and appropriate reimbursement.
• Identify documentation gaps, trends, and opportunities for improvement, and develop strategies to enhance documentation quality and consistency.
• Educate clinical staff on documentation best practices, regulatory requirements, and the impact of documentation on patient care, quality reporting, and reimbursement.
• Ensure clinical documentation complies with applicable regulatory standards, including CMS guidelines, HIPAA regulations, and other healthcare requirements.
• Analyze documentation quality and compliance data, prepare reports, and recommend process improvements to strengthen documentation practices.
• Partner with interdisciplinary teams to ensure documentation accurately reflects the patient's clinical condition, care provided, and treatment outcomes.

Qualifications

• Bachelor's Degree Nursing required or Master's Degree Nursing preferred
• Registered Nurse [RN - State License] - Massachusetts Licensure
• COS-C Certified - Required
• HCS-D - Certified - Required
• Clinical nursing experience 2-3 years required
• Clinical documentation experience 1-2 years preferred

Requirements

• No experience in lieu of a degree accepted

Benefits

• Competitive base pay
• Comprehensive benefits
• Career advancement opportunities
• Differentials, premiums, and bonuses as applicable
• Recognition programs designed to celebrate contributions and support professional growth

Company Description

Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham.