Clinical Documentation Specialist

The Clinical Documentation Specialist facilitates clarifications in clinical documentation through concurrent interaction with physicians and other members of the health care team to support that appropriate clinical severity is captured for the level of service rendered to all patients. Provide daily clinical evaluation of the medical record including physician and clinical documentation, lab results, diagnostic information and treatment plans. Be responsible for the day-to-day evaluation of documentation of the medical staff and healthcare team in accordance with the hospital's designated clinical documentation policies and procedures. Communicate with physicians, face-to-face and via clinical documentation inquiry forms, regarding missing, unclear or conflicting medical record documentation to clarify the information, obtain needed documentation, and educate for appropriate identification of severity of illness. Communicate with appropriate healthcare team members to ensure accurate and complete documentation is in the medical record. Demonstrate an understanding of complications, co-morbidities, severity of illness, risk of mortality, case mix, secondary diagnosis, impact of procedures on the final DRG, and an ability to impart this knowledge to physicians and other members of the healthcare team. Gather and analyze information pertinent to documentation findings and outcomes. About Brigham and Women's Faulkner Hospital Brigham and Women's Faulkner Hospital, an affiliate of Mass General Brigham, is committed to supporting patient care, research, teaching, and service to the community. We place great value on being a diverse, equitable and inclusive organization as we aim to reflect the diversity of the patients we serve. At Mass General Brigham, we believe in equal access to quality care, employment and advancement opportunities encompassing the full spectrum of human diversity: race, gender identity, sexual orientation, ability, religion, ethnicity, national origin and all the other forms of human presence and expression that make us better able to provide innovative and cutting-edge healthcare and research. Brigham and Women's Faulkner Hospital is a 171-bed non-profit, community teaching hospital located in Jamaica Plain directly across the street from the Arnold Arboretum. Founded in 1900, Brigham and Women's Faulkner Hospital offers comprehensive care in a wide variety of specialties. Brigham and Women's Faulkner Hospital is a designated Magnet hospital by the American Nurses Credentialing Center, a recognition that fewer than nine percent of all US hospitals receive. At Brigham and Women's Faulkner Hospital, we believe that everyone should have the chance to live a healthy life. From creating breakthroughs that have paved the way for treatments around the globe to training the next generation of providers, our patients, and those we may never meet, are at the center of everything we do. If you're looking for more than a career, join Brigham and Women's Faulkner Hospital. Our patients call it better care. Our employees call it home. Qualifications Bachelor's degree in nursing (BSN) required. Current RN license required. 5 years of acute medical/surgical care nursing required. 3 years of clinical documentation improvement experience required. Certification in Clinical Documentation (CCDS) strongly preferred. Excellent verbal and written communication skills. Proficiency in computer usage including database and spreadsheet analysis. Understanding of organizational policies and procedures. Working knowledge of quality improvement theory and procedures. Ability and willingness to seek out and accept change. EEO Statement Brigham and Women's Faulkner Hospital is an Affirmative Action 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. Primary Location: MA-Boston-BWFH Brigham and Women's Faulkner Hospital Main Work Locations: BWFH Brigham and Women's Faulkner Hospital Main 1153 Centre Street Boston 02130 Job: Nursing-Other Organization: Brigham & Women's Faulkner Hospital(BWFH) Schedule: Full-time Standard Hours: 40 Shift: Day Job Employee Status: Regular Recruiting Department: MGB Office of the Chief Medical Officer

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