Clinical Documentation Specialist

Spaulding Hospital - Boston and Cambridge
United States, Massachusetts, Boston
300 1st Avenue (Show on map)
May 03, 2025
Summary Facilitates improvement in the overall quality, completeness, and accuracy of medical record documentation for the purposes of ensuring compliance with Medicare and Medicaid (CMS) regulations and guidelines and expediting appropriate reimbursement. Utilizes both clinical and coding knowledge to obtain appropriate documentation through extensive interaction with physicians, nurses, other patient caregivers, and Revenue Cycle Operations (RCO) Coding staff and managers. Educates all members of the patient care team on documentation guidelines on an ongoing basis. Does this position require Patient Care? No Essential Functions -Analyze medical records, physician notes, and other clinical documentation to ensure accuracy, completeness, and compliance with industry standards and regulations. -Collaborate with coding teams to validate the accuracy and specificity of diagnostic and procedural codes based on clinical documentation. -Identify and rectify discrepancies or gaps in clinical documentation to accurately reflect the patient's severity of illness and risk of mortality. -Generate and communicate clinical documentation queries to healthcare providers to obtain additional information or clarification, following proper query protocols. -Educate clinicians and coding staff regarding accurate clinical documentation and coding. -Ensure clinical documentation meets all relevant regulatory requirements and coding guidelines, such as those from CMS and other governing bodies. Education Bachelor's Degree Nursing required Can this role accept experience in lieu of a degree? No Licenses and Credentials Registered Nurse [RN - State License] - Generic - HR Only required Experience Experience in clinical documentation improvement, coding, case management, or healthcare auditing 2-3 years preferred Knowledge, Skills and Abilities - In-depth knowledge of medical terminology, anatomy, and disease processes to accurately review clinical documentation. - Familiarity with ICD-10, CPT, and other coding systems and their application to clinical documentation. - Understanding of regulatory guidelines and compliance requirements related to clinical documentation, coding, and billing. - Analytical and critical thinking skills to assess the accuracy and completeness of clinical documentation. - Excellent written and verbal communication skills to effectively communicate with healthcare providers and other stakeholders. - Attention to detail and ability to work independently and collaboratively in a team-oriented healthcare environment. Physical Requirements Standing Occasionally (3-33%) Walking Occasionally (3-33%) Sitting Constantly (67-100%) Lifting Occasionally (3-33%) 20lbs - 35lbs Carrying Occasionally (3-33%) 20lbs - 35lbs Pushing Rarely (Less than 2%) Pulling Rarely (Less than 2%) Climbing Rarely (Less than 2%) Balancing Occasionally (3-33%) Stooping Occasionally (3-33%) Kneeling Rarely (Less than 2%) Crouching Rarely (Less than 2%) Crawling Rarely (Less than 2%) Reaching Occasionally (3-33%) Gross Manipulation (Handling) Constantly (67-100%) Fine Manipulation (Fingering) Frequently (34-66%) Feeling Constantly (67-100%) Foot Use Rarely (Less than 2%) Vision - Far Constantly (67-100%) Vision - Near Constantly (67-100%) Talking Constantly (67-100%) Hearing Constantly (67-100%) The Spaulding Rehabilitation Hospital Corporation is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.