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Clinical Documentation Specialist

Mass General Brigham Healthcare at Home
United States, Massachusetts, Newton
75-95 Wells Avenue (Show on map)
Jan 13, 2025
Summary
Responsible for improving the accuracy and completeness of clinical documentation, facilitating appropriate reimbursement, supporting quality care initiatives, and ensuring compliance with regulatory requirements.

Does this position require Patient Care?
No

Essential Functions
-Conduct thorough reviews of patient medical records to ensure accuracy, completeness, and compliance with established clinical documentation standards.

-Work closely with healthcare providers, including physicians, nurses, and other clinical staff, to clarify documentation and obtain necessary information to support accurate coding and billing.

-Provide guidance and clarification to coding staff regarding accurate and compliant documentation that supports appropriate code assignment and reimbursement.

-Identify documentation deficiencies and trends, and develop strategies to improve documentation practices to support quality patient care, accurate reporting, and compliance.

-Conduct training sessions and provide education to clinical staff regarding documentation best practices, regulatory requirements, and the impact on patient care and reimbursement.

-Ensure documentation adheres to regulatory standards, including but not limited to CMS guidelines, HIPAA regulations, and other relevant healthcare regulations.

-Compile data and generate reports on documentation quality, compliance, and areas for improvement, providing recommendations to enhance documentation practices.

-Collaborate with interdisciplinary teams to ensure comprehensive documentation that reflects the patient's clinical status, care provided, and outcomes.

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] - Generic - HR Only preferred

Experience
Clinical nursing experience 2-3 years required and Clinical documentation experience 1-2 years preferred

Knowledge, Skills and Abilities
- Strong understanding of clinical documentation standards, coding guidelines, and healthcare regulations.
- Ability to analyze medical records, identify deficiencies, and communicate effectively to improve documentation practices.
- Excellent verbal and written communication skills, including the ability to educate and train clinical staff effectively.
- Keen attention to detail and accuracy in reviewing medical records.
- Ability to work collaboratively within a multidisciplinary team.

Physical Requirements

  • Standing Frequently (34-66%)
  • Walking Frequently (34-66%)
  • Sitting Occasionally (3-33%)
  • Lifting Frequently (34-66%) 35lbs+ (w/assisted device)
  • Carrying Frequently (34-66%) 20lbs - 35lbs
  • Pushing Occasionally (3-33%)
  • Pulling Occasionally (3-33%)
  • Climbing Rarely (Less than 2%)
  • Balancing Frequently (34-66%)
  • Stooping Occasionally (3-33%)
  • Kneeling Occasionally (3-33%)
  • Crouching Occasionally (3-33%)
  • Crawling Rarely (Less than 2%)
  • Reaching Frequently (34-66%)
  • Gross Manipulation (Handling) Frequently (34-66%)
  • 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%)


Mass General Brigham Home Care, Inc. 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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