Clinical Documentation Specialist
Partner's Healthcare

Site: Mass General Brigham Home Care, Inc.

At Mass General Brigham, we know it takes a surprising range of talented professionals to advance our mission-from doctors, nurses, business people and tech experts, to dedicated researchers and systems analysts. As a not-for-profit organization, Mass General Brigham is committed to supporting patient care, research, teaching, and service to the community. We place great value on being a diverse, equitable and inclusive organization as we aim to reflect the diversity of the patients we serve.

At Mass General Brigham, we believe a diverse set of backgrounds and lived experiences makes us stronger by challenging our assumptions with new perspectives that can drive revolutionary discoveries in medical innovations in research and patient care. Therefore, we invite and welcome applicants from traditionally underrepresented groups in healthcare - people of color, people with disabilities, LGBTQ community, and/or gender expansive, first and second-generation immigrants, veterans, and people from different socioeconomic backgrounds - to apply.

Job Summary
Summary
Responsible for improving the accuracy and completeness of clinical documentation, facilitating appropriate reimbursement, supporting quality care initiatives, and ensuring compliance with regulatory requirements.

Does this position require Patient Care?
No

Essential Functions
-Conduct thorough reviews of patient medical records to ensure accuracy, completeness, and compliance with established clinical documentation standards.

-Work closely with healthcare providers, including physicians, nurses, and other clinical staff, to clarify documentation and obtain necessary information to support accurate coding and billing.

-Provide guidance and clarification to coding staff regarding accurate and compliant documentation that supports appropriate code assignment and reimbursement.

-Identify documentation deficiencies and trends, and develop strategies to improve documentation practices to support quality patient care, accurate reporting, and compliance.

-Conduct training sessions and provide education to clinical staff regarding documentation best practices, regulatory requirements, and the impact on patient care and reimbursement.

-Ensure documentation adheres to regulatory standards, including but not limited to CMS guidelines, HIPAA regulations, and other relevant healthcare regulations.

-Compile data and generate reports on documentation quality, compliance, and areas for improvement, providing recommendations to enhance documentation practices.

-Collaborate with interdisciplinary teams to ensure comprehensive documentation that reflects the patient's clinical status, care provided, and outcomes.

Qualifications

Education
Bachelor's Degree Nursing required or Master's Degree Nursing preferred

Can this role accept experience in lieu of a degree?
No

Licenses and Credentials
Registered Nurse [RN - State License] - Generic - HR Only preferred

Experience
Clinical nursing experience 2-3 years required and Clinical documentation experience 1-2 years preferred

Knowledge, Skills and Abilities
- Strong understanding of clinical documentation standards, coding guidelines, and healthcare regulations.
- Ability to analyze medical records, identify deficiencies, and communicate effectively to improve documentation practices.
- Excellent verbal and written communication skills, including the ability to educate and train clinical staff effectively.
- Keen attention to detail and accuracy in reviewing medical records.
- Ability to work collaboratively within a multidisciplinary team.

Additional Job Details (if applicable)

Physical Requirements

• Standing Frequently (34-66%)
• Walking Frequently (34-66%)
• Sitting Occasionally (3-33%)
• Lifting Frequently (34-66%) 35lbs+ (w/assisted device)
• Carrying Frequently (34-66%) 20lbs - 35lbs
• Pushing Occasionally (3-33%)
• Pulling Occasionally (3-33%)
• Climbing Rarely (Less than 2%)
• Balancing Frequently (34-66%)
• Stooping Occasionally (3-33%)
• Kneeling Occasionally (3-33%)
• Crouching Occasionally (3-33%)
• Crawling Rarely (Less than 2%)
• Reaching Frequently (34-66%)
• Gross Manipulation (Handling) Frequently (34-66%)
• Fine Manipulation (Fingering) Frequently (34-66%)
• Feeling Constantly (67-100%)
• Foot Use Rarely (Less than 2%)
• Vision - Far Constantly (67-100%)
• Vision - Near Constantly (67-100%)
• Talking Constantly (67-100%)
• Hearing Constantly (67-100%)

Remote Type

Remote

Work Location

75-95 Wells Ave

Scheduled Weekly Hours

40

Employee Type

Regular

Work Shift

Day (United States of America)

EEO Statement:

Mass General Brigham Home Care, Inc. is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.

Mass General Brigham Competency Framework

At Mass General Brigham, our competency framework defines what effective leadership "looks like" by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.

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