Clinical Document Specialist (RN)
Role Overview
This position plays a key role in maintaining the integrity of patient health records by reviewing inpatient documentation and collaborating with physicians and clinical staff. The specialist ensures that medical records accurately reflect the patient’s condition, treatment, and clinical progression throughout hospitalization.
Key Responsibilities
- Partner with physicians, nurses, and care teams to improve documentation accuracy and completeness, particularly around severity of illness and risk of mortality.
- Conduct ongoing reviews of inpatient records for specific payer groups or clinical specialties from admission through discharge.
- Evaluate patient clinical status, treatment plans, and medical history to detect potential documentation gaps.
- Engage attending physicians through verbal or electronic channels to clarify findings and recommend more precise or additional documentation.
- Support coding, billing, and quality reporting initiatives by ensuring documentation meets regulatory and reimbursement standards.
- Assist physician leaders with targeted reviews and special documentation improvement projects as needed.
Qualifications
Must hold active Massachusetts licensure as a Registered Nurse. Candidates must have direct patient care experience, or background in case management or utilization review. Familiarity with clinical documentation improvement principles and ICD-10-CM coding is required. Strong interpersonal abilities and experience communicating professionally with physicians are essential. Proficiency with electronic health records and data analysis systems is expected.
Preferred Background
- Bachelor’s degree in nursing or related field
- 1 to 3 years of experience in clinical documentation improvement
Technical Environment
Work involves regular use of ICD-10-CM coding standards, electronic health record platforms, and specialized software for data collection, analysis, and reporting.
Compensation & Benefits
Salary range is $87,276.80 to $157,081.60 per year, based on experience and qualifications. A signing bonus may be available. The position is full-time, with weekday day shifts totaling 40 hours per week. This is an onsite role located in the United States.
Work Environment
The organization fosters a culture where everyone contributes to patient care. Respect, collaboration, and inclusion are central to daily operations. The workplace supports diversity, equity, and accessibility, with accommodations available for employees with disabilities. Core values emphasize acknowledgment, active listening, responsive communication, teamwork, and kindness.
Equal Opportunity
All qualified applicants will be considered without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status. The organization actively encourages applications from individuals with diverse backgrounds and perspectives.
