Massachusetts Licensed Clinical Document Specialist

Job Summary

Collaborating with healthcare professionals, the full-time Massachusetts Licensed Clinical Document Specialist will ensure accurate medical record documentation, support coding and reimbursement processes, and communicate with physicians regarding documentation improvements in a primarily remote setting.

Key responsibilities

• Work collaboratively with physicians and staff to ensure complete and accurate medical record documentation
• Review inpatient medical records for identified payer populations and analyze clinical status to identify documentation gaps
• Communicate with attending physicians to validate observations and suggest enhancements to documentation

Required qualifications

• Massachusetts licensure as a registered nurse is required
• Experience in direct patient care, case management, or utilization review is required
• Knowledge of clinical documentation practices and ICD-10-CM diagnosis codes is required
• Excellent interpersonal skills with the ability to interact collaboratively with physicians
• Ability to effectively use specialized computer-based systems for data analysis and reporting