Mass General Brigham (Enterprise Services)
Clinical Documentation Specialist-Salem Hospital
Mass General Brigham (Enterprise Services), Somerville, Massachusetts, us, 02145
Clinical Documentation Specialist-Salem Hospital
United States, Massachusetts, Somerville This position combines clinical knowledge with collaboration, problem-solving, and a shared commitment to excellence. You'll be integral in shaping accurate documentation that influences outcomes, quality reporting, and overall healthcare delivery. Responsibilities: Conduct concurrent reviews of clinical documentation to ensure accuracy and completeness. Collaborate with healthcare teams, including medical, nursing, and coding staff, to identify documentation improvement opportunities. Assign working DRGs based on industry-standard guidelines and ensure appropriate reflection of patient conditions. Facilitate clear, professional, and compliant communication with providers to address incomplete or inconsistent documentation. Use clinical expertise to validate findings and support clinically credible queries for diagnoses or procedures. Meet or exceed key performance indicators (KPIs) for CDI activities. Apply Mass General Brigham values to guide decisions and actions, promoting a collaborative and inclusive work environment. Qualifications: Licensure: Current RN license required. Experience: At least 5 years of acute medical/surgical nursing and at least 3 years of CDI experience is required. Certification: Clinical Documentation Improvement certification is preferred. Mass General Brigham Incorporated 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.
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United States, Massachusetts, Somerville This position combines clinical knowledge with collaboration, problem-solving, and a shared commitment to excellence. You'll be integral in shaping accurate documentation that influences outcomes, quality reporting, and overall healthcare delivery. Responsibilities: Conduct concurrent reviews of clinical documentation to ensure accuracy and completeness. Collaborate with healthcare teams, including medical, nursing, and coding staff, to identify documentation improvement opportunities. Assign working DRGs based on industry-standard guidelines and ensure appropriate reflection of patient conditions. Facilitate clear, professional, and compliant communication with providers to address incomplete or inconsistent documentation. Use clinical expertise to validate findings and support clinically credible queries for diagnoses or procedures. Meet or exceed key performance indicators (KPIs) for CDI activities. Apply Mass General Brigham values to guide decisions and actions, promoting a collaborative and inclusive work environment. Qualifications: Licensure: Current RN license required. Experience: At least 5 years of acute medical/surgical nursing and at least 3 years of CDI experience is required. Certification: Clinical Documentation Improvement certification is preferred. Mass General Brigham Incorporated 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.
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