Clinical Documentation Specialist

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Clinical Documentation Specialist

Professional & Management Job ID: 34934

Schedule:

Full Time

Pay Range:

$37.00 - $73.00 / Hourly

Shift:

Day shift

Hours:

7a-3:30p

Medical Records

133 Old Road to Nine Acre Corner

Concord, MA 01742

Directions

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About this role

Improve Patient Care. Strengthen Documentation. Drive Impact.

About the Role

We're seeking a detail-oriented and collaborative Clinical Documentation Specialist (CDS) to join our Medical Records team. In this role, you will help ensure the accuracy, completeness, and integrity of clinical documentation-supporting high-quality patient care, regulatory compliance, and appropriate reimbursement.

Reporting to the Manager, Clinical Documentation & Coding, you will work closely with physicians, nurses, and interdisciplinary teams to ensure documentation reflects the full clinical picture. In this role, you will perform concurrent reviews of inpatient medical records to identify documentation gaps and opportunities to enhance the quality and accuracy of physician documentation.

If you thrive in a fast-paced clinical environment and enjoy combining clinical expertise with problem-solving and collaboration, this is a great opportunity to make a meaningful impact.

What You'll Do

• Review medical records to ensure accurate, complete, and compliant clinical documentation
• Collaborate with physicians and care teams to clarify and improve documentation quality
• Apply clinical and coding knowledge to support accurate code assignment and reimbursement
• Facilitate documentation improvement initiatives in both concurrent and retrospective reviews
• Educate providers and care teams on CMS regulations, documentation standards, and best practices
• Partner with coding professionals to ensure alignment between documentation and coding outcomes
• Support quality, compliance, and continuous improvement initiatives across the organization

What You Bring

Education

• Bachelor of Science in Nursing (BSN) or Bachelor of Science in Biology or a related healthcare clinical program (e.g., Medical Records/Health Information Management)

Experience

• One of the following:
• 3-5 years of acute care or equivalent clinical experience, or
• 3+ years of inpatient coding experience

Licensure & Certification

• Current Massachusetts Registered Nurse (RN) license and/or
• AHIMA coding certification (e.g., CCS, RHIT, RHIA) required

Skills & Competencies

• Ability to work independently and manage responsibilities with minimal supervision
• Strong verbal and written communication skills
• Proven ability to build effective working relationships with a wide range of healthcare providers
• Team-oriented mindset with strong collaboration and information-sharing skills
• Critical thinking and problem-solving abilities in complex clinical scenarios
• Strong organizational skills with the ability to stay focused despite frequent interruptions
• Proficiency with computer systems and ability to quickly learn new software applications
• Effective time management skills, with the ability to prioritize multiple tasks and meet deadlines
• Ability to interpret medical record documentation, prepare reports, and communicate findings clearly
• Comfort working with basic mathematical concepts such as percentages, ratios, and data analysis
• Knowledge of DPH regulations, Medicare/CMS rules and regulations
• Understanding of Joint Commission standards and continuous quality improvement (CQI) processes
• Commitment to maintaining strict confidentiality of patient and organizational information

Why Join Us?

• Make a direct impact on patient care quality and outcomes
• Collaborate with a dedicated, interdisciplinary healthcare team
• Expand your expertise in clinical documentation, compliance, and healthcare quality
• Competitive compensation and comprehensive benefits

Why Emerson

Emerson Health delivers world-class care to more than 300,000 patients throughout Concord and the surrounding region, and we bring that same commitment to our employees. Our teams work in a supportive, community-focused environment, backed by strong clinical partnerships and continued investment in innovation.

We offer competitive compensation and a comprehensive benefits package designed to support your health, your family, and your future, including:

• Medical and dental coverage
• Paid time off
• Retirement savings
• Tuition assistance
• Work-life resources
• Free parking on the hospital campus

Benefits are available to both full-time and eligible part-time employees.

Join a team that values compassion, collaboration, and caring for one another every day.

Apply Now

Benefits designed around you

We are a community hospital that values people's well-being. Our supportive environment, combined with a generous compensation and benefits package, allows you to balance your work and personal life, take care of your family and plan for your future.

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