Clinical Documentation Specialist, Home Care

Site: Mass General Brigham Home Care, Inc. Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham. Job Summary We are seeking a per diem Clinical Documentation Specialist to join the Utilization Management department supporting Mass General Brigham Home Care. The Clinical Documentation Improvement (CDI) Specialist is responsible for enhancing the accuracy, completeness, and quality of clinical documentation to support appropriate reimbursement, quality care initiatives, and compliance with regulatory requirements. Patient Care Requirement No Essential Functions Review patient medical records to ensure clinical documentation is accurate, complete, and compliant with established documentation standards. Collaborate with physicians, nurses, and other healthcare professionals to clarify documentation and obtain information necessary to support accurate coding and billing. Provide guidance to coding staff on documentation requirements that support accurate code assignment, regulatory compliance, and appropriate reimbursement. Identify documentation gaps, trends, and opportunities for improvement, and develop strategies to enhance documentation quality and consistency. Educate clinical staff on documentation best practices, regulatory requirements, and the impact of documentation on patient care, quality reporting, and reimbursement. Ensure clinical documentation complies with applicable regulatory standards, including CMS guidelines, HIPAA regulations, and other healthcare requirements. Analyze documentation quality and compliance data, prepare reports, and recommend process improvements to strengthen documentation practices. Partner with interdisciplinary teams to ensure documentation accurately reflects the patient's clinical condition, care provided, and treatment outcomes.

Qualifications

Education Bachelor's Degree Nursing required or Master's Degree Nursing preferred Can this role accept experience in lieu of a degree? No Licenses and Credentials Registered Nurse [RN - State License] - Massachusetts Licensure COS-C Certified - Required HCS-D - Certified - Required Experience Clinical nursing experience 2-3 years required and Clinical documentation experience 1-2 years preferred Additional Job Details (if applicable) Remote Type Remote Work Location 75-95 Wells Ave Scheduled Weekly Hours 0 Employee Type Per Diem Work Shift Day (United States of America) Pay Range $79,560.00 - $115,720.80/Annual Grade 7 At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into account your skills, relevant experience if applicable, education, certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass all elements contributing to your total compensation package. In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply, and our Talent Acquisition team will provide an overview of your potential compensation and benefits package. EEO Statement: 1410 Mass General Brigham Home Care, Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran’s Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources at (857)-282-7642. Mass General Brigham Competency Framework At Mass General Brigham, our competency framework defines what effective leadership “looks like” by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline. Combat disease. Hold a hand. Help people. Impact the world. Mass General Brigham is a passionate, welcoming community where minds meet caring hearts. Come be a part of the world’s most powerful force in medicine, where every role is important in changing lives. Are you ready? Our history includes New England hospitals founded over 200 years ago, some of the first and most prestigious hospitals in the world. Built on the legacy of two leading academic medical centers, we’re more than a system—we’re leaders in the practice of medicine. Mass General Brigham is committed to serving the community. We are dedicated to enhancing patient care, teaching and research, and taking a leadership role as an integrated health care system. We recognize that increasing value and continuously improving quality are essential to maintaining excellence.