Massachusetts Licensed Clinical Document Specialist

Job Summary

A company is looking for a Clinical Document Specialist (RN).

Key Responsibilities:

• Collaborates with healthcare team members to ensure accurate medical record documentation
• Reviews inpatient medical records for completeness and identifies documentation gaps
• Communicates with attending physicians to validate observations and suggest documentation improvements

Required Qualifications:

• Massachusetts licensure as a registered nurse required
• Experience in direct patient care, case management, or utilization review required
• Knowledge of clinical documentation practices and ICD-10-CM diagnosis codes required
• Ability to effectively use specialized computer systems for data analysis required
• Bachelor's degree preferred