Clinical Documentation Specialist

Job Ref: 18299
Category: Professional & Management
Emerson Hospital, 133 Old Road to Nine Acre Corner, Concord, MA 01742

Department: Medical Records
Schedule: Full Time
Shift: Day shift
Hours: 7-3:30

Reporting to the Director of Medical Records the Clinical Documentation Specialists facilitates improvement in the overall quality, completeness, and accuracy of medical record documentation for the purposes of ensuring compliance with Medicare and Medicaid (CMS) regulations and guidelines and to expedite appropriate reimbursement.  Utilizes both clinical and coding knowledge to obtain appropriate documentation through extensive interaction with physicians, nursing, other patient caregivers and Medical Record Clinical Coding Specialists.  Responsible for educating all members of the patient care team on documentation guidelines on an ongoing basis.

Minimum Qualifications:

§  Education:

Degree in Nursing or Medical Records

§  Experience:

3-5 years acute care nursing experience; or 3 years inpatient coding experience. 

§  Licensure and/or Certification:

Current RN license and/or AHIMA Coding Certification