Massachusetts Licensed Clinical Document Specialist

Job Summary

Collaborating closely with healthcare teams, the full-time Massachusetts Licensed Clinical Document Specialist will ensure accurate medical record documentation while working remotely, focusing on the complexity and intensity of patient care.

Key responsibilities

• Works collaboratively with physicians and staff to ensure accurate medical record documentation reflecting severity of illness
• Reviews inpatient medical records for payer populations, identifying gaps in physician documentation
• Communicates with attending physicians to validate observations and suggest documentation improvements

Required qualifications

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