Clinical Documentation Specialist

Emerson Hospital; West Concord (MA); On-site; USD 90,000 - 120,000; Full time

Job summary

Emerson Hospital in Massachusetts is seeking a Clinical Documentation Specialist to ensure accurate, complete documentation that supports compliant patient care and appropriate reimbursement.

You will perform concurrent reviews of inpatient records, collaborate with physicians and care teams to improve documentation quality, and educate providers on CMS regulations and documentation standards. Strong communication and teamwork are essential in this role.

Qualifications

• 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).
• 3–5 years of acute care or 3+ years of inpatient coding experience.
• Current Massachusetts RN license and/or AHIMA coding certification (CCS, RHIT, RHIA).
• Excellent verbal and written communication skills; ability to work independently and collaboratively.

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 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.

Skills

Strong communication skills

Collaboration

Problem-solving

Attention to detail

Education

BSN or biology-related degree

Job description

About the Role
We’re seeking a detail-oriented and collaborative Clinical Documentation Specialist (CDS) to join our Medical Recordsteam. 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, or
  • 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
• 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