Clinical Documentation Specialist

Emerson Hospital; Concord (MA); On-site; USD 77,000 - 152,000; Full time

Job summary

Emerson Hospital in Concord, MA seeks a Clinical Documentation Specialist to join the Medical Records team. You will review inpatient records, collaborate with physicians and care teams, and support accurate coding, documentation quality, and reimbursement.

The role requires a BSN or related healthcare degree, 3–5 years acute care or 3+ years inpatient coding, and active Massachusetts RN license or AHIMA certification. Strong communication and problem-solving are essential.

Qualifications

• BSN or related healthcare degree (e.g., Biology, Medical Records/Health Information Management).
• 3-5 years acute care or 3+ years inpatient coding experience.
• Massachusetts RN license and/or AHIMA coding certification (CCS/RHIT/RHIA) required.

Responsibilities

• Review medical records to ensure accurate, complete, and compliant clinical documentation.
• Collaborate with physicians and care teams to clarify and improve documentation quality.
• Apply clinical and coding knowledge to support accurate code assignment and reimbursement.
• Facilitate documentation improvement initiatives in concurrent and retrospective reviews.
• Educate providers on CMS regulations, documentation standards, and best practices.
• Partner with coding professionals to align documentation and coding outcomes.
• Support quality, compliance, and continuous improvement initiatives across the organization.

Skills

Attention to detail

Verbal and written communication

Collaboration

Problem solving

Time management

Independence

Analytical thinking

Education

BSN or related healthcare degree

Tools

EHR systems

Coding software

Job description

Clinical Documentation Specialist

Schedule: Full Time

Pay Range: $37.00 - $73.00 / Hourly

Shift: Day shift

Hours: 7a-3:30p

About this role

Improve Patient Care. Strengthen Documentation. Drive Impact.

About the Role

We're seeking a detail-oriented and collaborative Clinical Documentation Specialist (CDS) to join our Medical Records team. In this role, you will help ensure the accuracy, completeness, and integrity of clinical documentation-supporting high-quality patient care, regulatory compliance, and appropriate reimbursement.

Reporting to the Manager, Clinical Documentation & Coding, you will work closely with physicians, nurses, and interdisciplinary teams to ensure documentation reflects the full clinical picture. In this role, you will perform concurrent reviews of inpatient medical records to identify documentation gaps and opportunities to enhance the quality and accuracy of physician documentation.

If you thrive in a fast-paced clinical environment and enjoy combining clinical expertise with problem-solving and collaboration, this is a great opportunity to make a meaningful impact.

What You'll Do

• Review medical records to ensure accurate, complete, and compliant clinical documentation
• Collaborate with physicians and care teams to clarify and improve documentation quality
• Apply clinical and coding knowledge to support accurate code assignment and reimbursement
• Facilitate documentation improvement initiatives in both concurrent and retrospective reviews
• Educate providers and care teams on CMS regulations, documentation standards, and best practices
• Partner with coding professionals to ensure alignment between documentation and coding outcomes
• Support quality, compliance, and continuous improvement initiatives across the organization

What You Bring

Education

• Bachelor of Science in Nursing (BSN) or Bachelor of Science in Biology or a related healthcare clinical program (e.g., Medical Records/Health Information Management)

Experience

One of the following:

• 3-5 years of acute care or equivalent clinical experience
• 3+ years of inpatient coding experience

Licensure & Certification

• Current Massachusetts Registered Nurse (RN) license and/or
• AHIMA coding certification (e.g., CCS, RHIT, RHIA) required

Skills & Competencies

• Ability to work independently and manage responsibilities with minimal supervision
• Strong verbal and written communication skills
• Proven ability to build effective working relationships with a wide range of healthcare providers
• Team-oriented mindset with strong collaboration and information-sharing skills
• Critical thinking and problem-solving abilities in complex clinical scenarios
• Strong organizational skills with the ability to stay focused despite frequent interruptions
• Proficiency with computer systems and ability to quickly learn new software applications
• Effective time management skills, with the ability to prioritize multiple tasks and meet deadlines
• Ability to interpret medical record documentation, prepare reports, and communicate findings clearly
• Comfort working with basic mathematical concepts such as percentages, ratios, and data analysis
• Knowledge of DPH regulations, Medicare/CMS rules and regulations
• Understanding of Joint Commission standards and continuous quality improvement (CQI) processes
• Commitment to maintaining strict confidentiality of patient and organizational information

Why Join Us?

• Make a direct impact on patient care quality and outcomes
• Collaborate with a dedicated, interdisciplinary healthcare team
• Expand your expertise in clinical documentation, compliance, and healthcare quality
• Competitive compensation and comprehensive benefits