Top 102 Clinical documentation specialist Jobs in Massachusetts

Clinical Documentation Specialist II- RN- Remote
Beth Israel Lahey Health —Charlestown, MA
- $102,000 - $158,392 a year
- Full-time
- Remote
- Nursing
- Microsoft Excel
- Microsoft Outlook
Clinical Documentation Improvement Specialist
Beth Israel Lahey Health —Charlestown, MA
- $102,000 - $158,392 a year
- Full-time
- Nursing
- Microsoft Excel
- Microsoft Outlook
Clinical Review Specialist
Mass General Brigham Community Physicians, Inc. —Somerville, MA
- $63,648.00 - $92,570.40 a year
- Full-time
- Remote
- Nursing
- RN License
- Mid-level
- Opportunities for advancement
Quick Apply
5d
Senior Consultant - Clinical Documentation Specialist
Deloitte —Boston, MA
- $110,700 - $218,300 a year
- Full-time
- Microsoft Word
- Nursing
- RN License
Clinical Data Specialist
Iterative Health —Cambridge, MA
- Hybrid work
- Mid-level
- Office
- Bachelor's degree
- Health savings account
- Disability insurance
Quick Apply
Clinical Regulatory Specialist
Iterative Health —Cambridge, MA
- Hybrid work
- Mid-level
- Office
- 2 years
- Health savings account
- Disability insurance
Quick Apply
6d
Clinical Audit Response Specialist
Dana-Farber Cancer Institute —Boston, MA
- $110,200 - $122,300 a year
- Full-time
- Nursing
- RN License
- 5 years
Credentialing Spec (PD)
UMass Memorial Health —Worcester, MA
- $19.21 - $34.59 an hour
- 8 hour shift
- Remote
- Microsoft Word
- Mid-level
- Office
2d
Outpatient Coder II
UMass Memorial Health —Worcester, MA
- 8 hour shift
- Remote
- Customer service
- Mid-level
- High school diploma or GED
Medical Staff Office Specialist
Beth Israel Lahey Health —Woburn, MA
- $31.63 - $41.73 an hour
- Full-time
- Hospital
- Customer service
- Mid-level
Senior Specialist, Biosamples
Tango Therapeutics —Boston, MA
- $90,400 - $135,600 a year
- Mid-level
- 3 years
- Bachelor's degree
Occupational Health Informatics Specialist
Harvard University —Cambridge, MA
- Full-time
- Hybrid work
- Nursing
- RN License
- 5 years
- Commuter assistance
- Health insurance
Senior Clinical Regulatory Specialist
Iterative Health —Cambridge, MA
- Hybrid work
- Office
- Mentoring
- Senior level
- Health savings account
- Disability insurance
Quick Apply
3d
Clinical Research Associate
Aya Healthcare —Boston, MA
- $70 - $75 an hour
- Contract
- Hybrid work
- Background check
- Mid-level
- 3 years
- Travel reimbursement
- Health insurance
Quick Apply
3d
Medical Billing Manager
Tallman Eye Associates —Lawrence, MA
- $66,000 - $75,000 a year
- 8 hour shift
- Mid-level
- Office
- 3 years
- Health insurance
- Dental insurance
Quick Apply
NICU RN-Nights-4 week contract, Framingham, MA
Prolink —Framingham, MA
- $3,600 a week
- Overnight shift
- Background check
- Anatomy knowledge
- Medication administration
- Health savings account
- Health insurance
Quick Apply
NICU RN-Nights-4 week contract, Worcester, MA
Prolink —Worcester, MA
- $3,600 a week
- Overnight shift
- Anatomy knowledge
- Medication administration
- Patient monitoring
- Health savings account
- Health insurance
Quick Apply
Haverhill Pavilion - Utilization Specialist
Haverhill Behavioral Health —Haverhill, MA
- Full-time
- CPR Certification
- Nursing
- RN License
Research Coordinator
VA Boston Healthcare System —Boston, MA
- Full-time
- Background check
- Mid-level
- Administrative experience
- Health savings account
- Health insurance
Quick Apply
Registered Nurse
Arbor Associates —Pittsfield, MA
- $37 - $55 an hour
- Contract
- Background check
- 18 years or older
- Patient monitoring
Quick Apply
10d

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Clinical Documentation Specialist II- RN- Remote

Beth Israel Lahey Health -
Charlestown, MA

Apply Now

Job Details

Full-time
$102,000 - $158,392 a year

Qualifications

Medical writing
Inpatient experience
RN License
Bachelor's degree
Medical-surgical
Desktop applications
Bachelor's degree in nursing
Manual chart audits
Clinical documentation improvement
Surgical nursing expertise

Full Job Description

Charlestown, MA • Beth Israel Lahey Health • Full-time • Day

When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives.

**This position is remote. Candidates must be local to New England States for consideration**

The Clinical Documentation Improvement (CDI) Specialist II assists with the appropriate identification of diagnoses, conditions, and/or procedures that are representative of the patient’s hospital stay and care provided including Severity of Illness (SOI), Risk of Mortality (ROM), during an inpatient hospitalization. CDI Specialist II initiates concurrent queries to providers as supported by medical record documentation to improve the accuracy, integrity, and quality of patient data, and drive improvement toward quality physician documentation within the body of the medical record. The CDI Specialist II works under the direction of the Manager of CDI and collaborates with coding, clinicians, medical staff, and physician advisors to improve documentation and the importance of complete and accurate documentation.

Job Description:

Concurrently reviews inpatient records to ensure completeness, accuracy, and clinical validation.
Evaluates documentation for assignment of working and possible DRG.
Recognizes opportunities for documentation improvement, including severity of illness, risk of mortality, core measures, and patient safety/quality.
Identify opportunities to query physicians regarding missing, unclear, or conflicting documentation.
Interacts directly with physicians to request and obtain additional documentation when needed.
Timely follow-up on all unanswered queries based on the query escalation policy.
Facilitates modifications to physician documentation to reflect the complexity of care of the patient and appropriate reimbursement.
Maintains a collaborative working relationship with the Health Information Coding staff and serves as a clinical resource.
Collaborates with and educates members of the patient care team regarding documentation guidelines, including physicians, allied health practitioners, nursing, and case management.
Performs mortality reviews and optimizes the risk of mortality.
Maintains review worksheet on all records using CDI software.
Ensures the accuracy of clinical information used for measuring and reporting physician and hospital quality outcomes.
Reviews, evaluates, analyzes, and interprets data related to documentation on an ongoing basis. Identifies trends or potential problems and assists in developing action plans to address.
Participates in additional projects such as developing physician education materials, CDI week advertisements, etc.
Adheres to ethical and professional business practices.
All other duties as assigned.
It is understood that this is a summary of key job functions and does not include every detail of the job that may reasonably be required.

Minimum Qualifications:

Education:

Bachelor’s in Nursing, required

Licensure, Certification & Registration:

RN License
Clinical Documentation Specialist Certification via ACDIS or AHIMA

Experience:

2-5 years of medical/surgical nursing experience in the acute hospital setting.
Experienced Clinical Documentation Specialist with minimum of 2 years recent experience in CDI role
Critical Care and/or Emergency Nursing experience required

Skills, Knowledge & Abilities:

Proficient skill in query writing to physicians
Knowledge to accurately complete chart audits
Organizational and critical thinking skills required
Experience with computer systems required, including web-based applications and some Microsoft Office applications which may include Outlook, Word, Excel, PowerPoint, or Access

Pay Range:

$102,000.00 USD – $158,392.00 USD

The pay range listed for this position is the annual base salary range the organization reasonably and in good faith expects to pay for this position at this time. Actual compensation is determined based on several factors, that may include seniority, education, training, relevant experience, relevant certifications, geography of work location, job responsibilities, or other applicable factors permissible by law.

As a health care organization, we have a responsibility to do everything in our power to care for and protect our patients, our colleagues and our communities. Beth Israel Lahey Health requires that all staff be vaccinated against influenza (flu) as a condition of employment.

More than 35,000 people working together. Nurses, doctors, technicians, therapists, researchers, teachers and more, making a difference in patients' lives. Your skill and compassion can make us even stronger.

Equal Opportunity Employer/Veterans/Disabled

Job details

Employment: Full-time
Hours/Week: 40
Shift: Day
Category: Clinical Documentation Improvement (CDI)
Pay Range: $102,000.00 USD - $158,392.00 USD
FLSA: Exempt
Req ID: JR84553

Apply Now

Refine Your Search

clinical documentation specialist jobs in massachusetts

Clinical Documentation Specialist II- RN- Remote

Clinical Documentation Improvement Specialist

Clinical Review Specialist

Senior Consultant - Clinical Documentation Specialist

Clinical Data Specialist

Clinical Regulatory Specialist

Clinical Audit Response Specialist

Credentialing Spec (PD)

Outpatient Coder II

Medical Staff Office Specialist

Senior Specialist, Biosamples

Occupational Health Informatics Specialist

Senior Clinical Regulatory Specialist

Clinical Research Associate

Medical Billing Manager

NICU RN-Nights-4 week contract, Framingham, MA

NICU RN-Nights-4 week contract, Worcester, MA

Haverhill Pavilion - Utilization Specialist

Research Coordinator

Registered Nurse

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As a health care organization, we have a responsibility to do everything in our power to care for and protect our patients, our colleagues and our communities. Beth Israel Lahey Health requires that all staff be vaccinated against influenza (flu) as a condition of employment.

More than 35,000 people working together. Nurses, doctors, technicians, therapists, researchers, teachers and more, making a difference in patients' lives. Your skill and compassion can make us even stronger.

Equal Opportunity Employer/Veterans/Disabled

Job details

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