Clinical Documentation Specialist, Home Care
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AI Summary
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.
Job Summary
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.
Patient Care Requirement
No
Essential Functions
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
Education
Bachelor's Degree Nursing required or Master's Degree Nursing preferred
Can this role accept experience in lieu of a degree?
No
Licenses and Credentials
Registered Nurse [RN - State License] - Massachusetts Licensure
COS-C Certified - Required
HCS-D - Certified - Required
Experience
Clinical nursing experience 2-3 years required and Clinical documentation experience 1-2 years preferred
Additional Job Details (if applicable)
Remote Type
Work Location
Scheduled Weekly Hours
Employee Type
Work Shift
Pay Range
$79,560.00 - $115,720.80/Annual
Grade
7
EEO Statement:
Mass General Brigham Competency Framework
At Mass General Brigham, our competency framework defines what effective leadership “looks like” by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.
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