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Clinical Documentation Specialist, Per Diem
Boston Medical Center (BMC). Provide clinically based concurrent and retrospective review of inpatient medical records .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in clinical documentation improvement, inpatient case management, and reimbursement processes, with a strong foundation in nursing or health information management. Proficient in evaluating medical records to ensure compliance and accuracy in patient care documentation.
Highest-signal resume keywords
Bachelor’s Degree In NursingRN CertificationInpatient Case Management ExperienceClinical Documentation Improvement (CDI)Knowledge Of Medicare Reimbursement System
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Clinical Documentation ReviewUtilization EvaluationInpatient CodingDRG ValidationPathology UnderstandingPhysiology UnderstandingCare Delivery Documentation SystemsAge-Specific Needs KnowledgeCritical ThinkingComputer Literacy
Soft Skills
Excellent Written CommunicationExcellent Verbal CommunicationAbility To Work IndependentlyAdaptabilityPrioritization
Certifications & Qualifications
CCS CertificationCCDS Certification
Industry Keywords
Acute Care ServicesQuality Of Care OutcomesInpatient Admission CriteriaRegulatory CompliancePhysician Communication
About the role
Key responsibilities & impact- Provide clinically based concurrent and retrospective review of inpatient medical records
- Evaluate utilization and documentation of acute care services
- Facilitate appropriate physician documentation to accurately reflect patient severity of illness and risk of mortality
- Conduct reviews determined internally and by external payers or regulatory agencies
- Support accurate and compliant reimbursement for acute care services
- Contribute to reporting quality-of-care outcomes
Requirements
What you’ll need- Bachelor’s degree in Nursing or Health Information Management is required, or equivalent combination of education and experience
- RN or CCS required
- CCDS preferred
- Minimum 6 years related experience, including either 6 years clinical experience with 3 years inpatient case management experience or 6 years inpatient coding with DRG Validation
- Previous CDS experience preferred
- Knowledge of care delivery documentation systems and related medical record documents
- Knowledge of age-specific needs, disease processes, and related procedures
- Broad-based clinical knowledge and understanding of pathology/physiology
- Excellent written and verbal communication skills
- Excellent critical thinking skills
- Working knowledge of inpatient admission criteria
- Ability to work independently in a time-oriented environment
- Computer literacy and familiarity with basic office equipment
- Ability to facilitate ongoing physician communication
- Ability to adapt to workload changes and effectively prioritize work assignments
- Working knowledge of Medicare reimbursement system and coding structures preferred but not required
Benefits
Comp & perks- Medical, dental, vision, and pharmacy benefits
- Contract increases
- Flexible Spending Accounts
- 403(b) savings matches
- Earned time cash out
- Paid time off
- Career advancement opportunities
- Resources to support employee and family wellbeing