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Job description
Clinical Documentation Specialist - Hybrid
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 documentation
Collaborate with physicians and care teams to clarify and improve documentation quality
Apply clinical and coding knowledge to support accurate code assignment and reimbursement
Facilitate documentation improvement initiatives in both concurrent and retrospective reviews
Educate providers and care teams on CMS regulations, documentation standards, and best practices
Partner with coding professionals to ensure alignment between documentation and coding outcomes
Support 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, or
3+ years of inpatient coding experience
Licensure & Certification
Current Massachusetts Registered Nurse (RN) license and/or
AHIMA coding certification (e.g., CCS, RHIT, RHIA) required
Skills & Competencies
Ability to work independently and manage responsibilities with minimal supervision
Strong verbal and written communication skills
Proven ability to build effective working relationships with a wide range of healthcare providers
Team-oriented mindset with strong collaboration and information-sharing skills
Critical thinking and problem-solving abilities in complex clinical scenarios
Strong organizational skills with the ability to stay focused despite frequent interruptions
Proficiency with computer systems and ability to quickly learn new software applications
Effective time management skills, with the ability to prioritize multiple tasks and meet deadlines
Ability to interpret medical record documentation, prepare reports, and communicate findings clearly
Comfort working with basic mathematical concepts such as percentages, ratios, and data analysis
Knowledge of DPH regulations, Medicare/CMS rules and regulations
Understanding of Joint Commission standards and continuous quality improvement (CQI) processes
Commitment to maintaining strict confidentiality of patient and organizational information
Why Join Us?
Make a direct impact on patient care quality and outcomes
Collaborate with a dedicated, interdisciplinary healthcare team
Expand your expertise in clinical documentation, compliance, and healthcare quality
Competitive compensation and comprehensive benefits
To apply, please visit: jobs/clinical-documentation-specialist-hybrid-34934/
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