RN Clinical Documentation Improvement Specialist

South Shore Health System; South Weymouth (MA); On-site; USD 90,000 - 120,000; Full time

Job summary

South Shore Health System seeks a Clinical Documentation Improvement Specialist to develop and maintain documentation accuracy across inpatient and observation cases. The role involves on-site collaboration with physicians and HIM staff to ensure documentation supports illness severity and appropriate reimbursement.

The ideal candidate will hold an RN license in Massachusetts, have 5 years of nursing experience with coding education, and preferably CCS certification.

Qualifications

• Graduate from an accredited school of nursing with a license to practice professional nursing in Massachusetts.
• Five (5) years nursing experience with coding education; Clinical Documentation Improvement (CDI) experience preferred.
• RN license required; CCS certification preferred.

Responsibilities

• Perform concurrent review to ensure documentation reflects severity of illness and assigns working DRG.
• Educate physicians and staff on documentation best practices and DAP concepts.
• Collaborate with Health Information Management and CDI team to improve program effectiveness.
• Review data to identify trends and develop action plans.

Skills

Nursing experience

CDI experience

Coding education

Communication skills

Leadership

Education

RN license

BSN preferred

CCS certification preferred

Job description

South Shore Health System seeks a Clinical Documentation Improvement Specialist to develop and maintain documentation accuracy across inpatient and observation cases. The role involves on-site collaboration with physicians and HIM staff to ensure documentation supports illness severity and appropriate reimbursement.

The ideal candidate will hold an RN license in Massachusetts, have 5 years of nursing experience with coding education, and preferably CCS certification.