Clinical Documentation Specialist - Hybrid

Emerson Hospital; Concord (MA); Hybrid; USD 51,000 - 101,000; Full time

Benefits offered by this job

Hybrid work model

Competitive compensation

Comprehensive benefits

Job summary

Emerson Hospital in Massachusetts is seeking a Clinical Documentation Specialist to join the Medical Records team. The role is hybrid, focusing on accurate documentation, coding alignment, and regulatory compliance to improve patient care and reimbursement.

You will review records, educate clinicians, and collaborate with care teams to close documentation gaps in a fast-paced clinical environment.

Qualifications

• BSN or related healthcare program is required.
• Current Massachusetts RN license and AHIMA coding certification required.
• Experience in clinical documentation and coding is preferred.

Responsibilities

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

Skills

Independence

Communication

Relationship building

Teamwork

Critical thinking

Organization

Computer skills

Time management

Documentation interpretation

Data analysis

Regulatory knowledge

CQI

Confidentiality

Education

BSN or related healthcare program

RN license

AHIMA coding certification (CCS, RHIT, RHIA)

Job description

Clinical Documentation Specialist - Hybrid

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, 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

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