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Clinical Documentation Specialist

Job ID R1558 Full / Part Time:Full time


The Clinical Documentation Specialist acts as a liaison between medical staff, Nursing, Coding and QI specialist to ensure the clinical documentation supports and reflects the most appropriate level of services and resources provided.

Job Responsibilities: 

  •  Provides clinically based concurrent review of inpatient medical records to assess and procure accurate and complete documentation of the patients' diagnoses and procedures
  • Ensures documentation accurately reflects quality of care, severity of illness and risk of mortality to support correct coding, reimbursement and quality initiatives.
  • Proactively contacts physicians or other departments regarding procedures/diagnoses to ensure proper documentation. This includes joining physicians and other clinical staff in educational sessions and "rounds" on the nursing units. Participates, when appropriate, with questions to improve overall documentation of the care being rendered to the patient.
  • Identifies opportunities to improve documentation and coding workflow process. Collaborates with the HIM managment and staff.
  • Prepares and presents educational sessions to physicians on proper documentation.
  • Monitors and participates in performance improvement initiatives.
  • Participates in the planning for assigned inter/intra departmental meetings and presentations
  • Participates in professional development and activities to keep current with trends in coding. This can include offsite meetings/conferences/site visits where travel and overnight stay might be required.
  • Communicates effectively and adaptable to a wide variety of interpersonal environments within the entire healthcare system. Able to be an approachable liaison to facilitate the achievement of CDI goals.
  • All tasks need to be performed following the Operating Principles of Baystate Health. Adheres to system and department compliance policies, and any and all applicable laws and regulations. Performs other duties as assigned

Required Work Experience: 

  •  5 years in an acute care setting; If Physician trained experience, RN will not be required

Preferred Work Experience: 

Certifications:  RHIA, RHIT, CDS, CCS is preferred.

  • Anatomy and Physiology Medical Terminology is required.
  • 5+ years of Clinical Documentation Specialist is preferred.
  • CCS/CDS/ICD 10  is preferred.
  • Familiarity with Cerner and 3M applications.

Skills and Competencies: 

  • Extensive clinical knowledge and understanding of pathology/physiology; best demonstrated by clinical experience in hospital setting


Diploma in Nursing: Anatomy (Required)



Certified Clinical Documentation Special - Various, Certified Coding Specialist - American Health Information Management Association, Registered Health Information Associate - American Health Information Management Association, Registered Health Information Technician - American Health Information Management Association, Registered Nurse - State of Massachusetts

Work Experience:




Training Details:

Baystate Health is an Equal Opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, marital status, national origin, ancestry, age, genetic information, disability, or protected veteran status.

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