Clinical Documentation Specialist, Per Diem

Boston Medical Center; United States; On-site; USD 52,000 - 103,000; Part time

Job summary

Boston Medical Center seeks a Clinical Documentation Specialist to perform concurrent and retrospective reviews of inpatient records, ensuring accurate documentation and appropriate reimbursement. The role emphasizes physician communication and QA for severity of illness and mortality risk, with a focus on compliant coding and reporting.

The position is part-time and union-per-diem, requiring an RN or CCS with 6+ years of clinical/inpatient experience.

Qualifications

• Bachelor’s degree required; nursing or HIM emphasis preferred.
• RN or CCS certification required; CCDS/CDIP preferred.
• Minimum 6 years related experience including inpatient case management or coding with DRG validation.

Responsibilities

• Perform concurrent and retrospective reviews of inpatient records to evaluate utilization and documentation.
• Facilitate physician documentation to accurately reflect severity of illness and mortality risk.
• Collaborate with care teams to ensure compliant reimbursement and report quality outcomes.

Skills

CDS experience

Inpatient coding

Communication

Healthcare documentation

Education

Bachelor’s degree in Nursing or Health Information Management

Tools

EHR systems

Job description

POSITION SUMMARY: The Clinical Documentation Specialist (CDS) will provide clinically based concurrent and retrospective review of inpatient medical records to evaluate the utilization and documentation of acute care services. The goal of concurrent review includes facilitation of appropriate physician documentation of care delivery to accurately reflect patient severity of illness and risk of mortality. Specific reviews are both determined internally and by requirements/requests of external payers or regulatory agencies and play a significant role in reporting quality of care outcomes and in obtaining accurate and compliant reimbursement for acute care services.

Position: Clinical Documentation Specialist Department: Clinical Documentation Schedule: Part Time, 1199SEIU Union Per Diem

JOB REQUIREMENTS EDUCATION: Bachelor’s degree in Nursing or Health Information Management is required; however, an equivalent combination of education and experience, which provides proficiency in the areas of responsibility, may be substituted for the stated education and experience requirements.

CERTIFICATES, LICENSES, REGISTRATIONS REQUIRED: RN or CCS, required. CCDS, CDIP preferred.

EXPERIENCE: Minimum 6 years related experience (i.e. 6 years clinical experience including 3 years inpatient case management experience or 6 years of experience inpatient coding with DRG Validation required). Previous CDS experience preferred.

KNOWLEDGE AND SKILLS: Knowledge of care delivery documentation systems and related medical record documents. Knowledge of age-specific needs and the elements of disease processes and related procedures. Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes. Excellent written and verbal communication skills. Excellent critical thinking skills. Demonstrated employee and medical staff relationships in the past and has the ability to maintain those going forward. Working knowledge of inpatient admission criteria. Ability to work independently in a time-oriented environment. Computer literacy and familiarity with the operation of basic office equipment. Assertive personality traits to facilitate ongoing physician communication. Ability to be adapt to changes in the workload, to work independently and effectively prioritize work assignments Working knowledge of Medicare reimbursement system and coding structures preferred, but not required.

Compensation Range: $38.05- $75.33 This range offers an estimate based on the minimum job qualifications. However, our approach to determining base pay is comprehensive, and a broad range of factors is considered when making an offer. This includes education, experience, and licensure/certifications directly related to position requirements. In addition, BMCHS offers generous total compensation that includes, but is not limited to, benefits (medical, dental, vision, pharmacy), contract increases, Flexible Spending Accounts, 403(b) savings matches, earned time cash out, paid time off, career advancement opportunities, and resources to support employee and family wellbeing.

Equal Opportunity Employer/Disabled/Veterans

Working at Boston Medical Center is more than a job. It’s a chance to make a difference as part of our mission to provide exceptional and equitable care to all. As a nationally-recognized leader in health equity, nursing, initiatives to combat climate change, and many other areas, BMC is dedicated to improving the health of our community in Boston and beyond. BMC’s mission to provide exceptional care without exception extends to our employees, and we have been recognized as a top employer and best place to work. A strong sense of teamwork and support for our staff are the bedrock of BMC, as we know that we can only provide exceptional care to patients when our staff are cared for too.

Boston Medical Center is an equal employment/affirmative action employer. We ensure equal employment opportunities for all, without regard to race, color, religion, sex, national origin, age, disability, veteran status, sexual orientation, gender identity and/or expression or any other non-job-related characteristic.

If you need accommodation for any part of the application process because of a medical condition or disability, please send an e-mail to [e-mail] or call 617-638-8582 to let us know the nature of your request.

Boston Medical Center participates in the Electronic Employment Verification Program. As an E-Verify employer, prospective employees of BMC must complete a background check before beginning their employment at the hospital.

BMC requires all staff to be vaccinated against COVID-19 and flu, as well as receive a booster dose of the COVID-19 vaccine.