Clinical Documentation Specialist: Elevate Care Quality

Boston Medical Center (BMC); Boston (MA); On-site; USD 52,000 - 103,000; Part time

Job summary

Boston Medical Center (BMC) seeks a Clinical Documentation Specialist to perform concurrent and retrospective reviews of inpatient records, ensuring accurate documentation of care delivery and appropriate reimbursement. The role requires strong clinical knowledge and excellent communication to support physicians and care teams.

The CDS will work in Clinical Documentation with a focus on education, compliance, and documentation improvement, coordinating with payers and regulatory bodies as needed.

Qualifications

• Bachelor’s degree in Nursing or Health Information Management required or equivalent experience.
• RN or CCS certification required.
• CCDS or CDIP preferred but not required.

Responsibilities

• Conduct concurrent and retrospective reviews of inpatient records to evaluate utilization and documentation.
• Facilitate accurate physician documentation to reflect severity of illness and mortality risk.
• Collaborate with care teams and external payers/regulators to support compliant reimbursement.

Skills

Documentation

Communication

Critical thinking

Clinical knowledge

Independence

Education

Bachelor’s degree in Nursing or Health Information Management

RN or CCS required

CCDS, CDIP preferred

Job description

Boston Medical Center (BMC) seeks a Clinical Documentation Specialist to perform concurrent and retrospective reviews of inpatient records, ensuring accurate documentation of care delivery and appropriate reimbursement. The role requires strong clinical knowledge and excellent communication to support physicians and care teams.

The CDS will work in Clinical Documentation with a focus on education, compliance, and documentation improvement, coordinating with payers and regulatory bodies as needed.