Tenet Healthcare Clinical Documentation Specialist Full Time in Framingham, Massachusetts

General Summary:

Under general supervision of the Regional Director of Clinical Documentation Improvement, the Clinical Documentation Specialist is responsible for improving overall quality and completeness of clinical documentation to accurately reflect patient severity of illness and risk of mortality through extensive interaction with physician, case management, nursing staff, other patient caregivers and coding staff.

Essential Duties:

  1. Initiates and performs concurrent documentation review of selected inpatient records to clarify conditions/diagnosis and procedures where inadequate or conflicting documentation is suspected.

  2. Communicates with individual physician or medical staff departments to facilitate complete and accurate documentation of the inpatient medical record.

  3. Serves as a resource for physician to help link ICD-9-CM coding guidelines and medical terminology to improve accuracy of final code assignment.

  4. Works in collaborative fashion with coders and case managers concurrently reviewing the inpatient medical record to assure a correct provisional and final DRG assignment.

  5. Monitors and evaluates effectiveness of concurrent chart review and query outcomes at designated intervals.

  6. Reports concurrent chart review and query outcomes to hospital departments and committees at designated intervals.

  7. Performs monthly closed chart reviews and serves on the Utilization Review Committee.

  8. Identifies, assist and participates in intradepartmental and interdepartmental special projects involving the accuracy of physician documentation.

  9. Works in a collaborative fashion with the MSDRG Physician Advisor in identifying patterns of physician documentation issues, utilization/follow up of queries and education of physicians at the bedside and/or weekly meetings.

Additional Responsibilities:

Performs other duties as assigned.


  1. RHIT, RHIA, RN, or CCS required

  2. Two years of experience in acute care setting.

  3. Knowledge of care delivery documentation systems and related medical record documents.

  4. Detail knowledge and understanding and MSDRGs and OIG workplan as it relates to correct coding and MSDRG assignment.

  5. One year of inpatient coder experience preferred.

  6. Excellent written and verbal communication skills, critical thinking skills and interpersonal skills to build effective relationships with physician, case management, nursing, coding staff and hospital staff.

Job: Non-Clinical/Administrative

Organization: MetroWest Framingham Union Hospital

Title: Clinical Documentation Specialist Full Time

Location: MA-Framingham

Requisition ID: 1805037974