Baystate Health Clinical Documentation Specialist RN in Holyoke, Massachusetts

Clinical Documentation Specialist RN

Full/Part Time


Job ID



Holyoke, Massachusetts



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.

Baystate Healthis an integrated health care delivery system serving a population of nearly 1 million people in western Massachusetts. We are one of the largest health systems in New England with over 11,500 employees, five hospitals, and over 60 medical practices. Baystate Medical Center is the onlyLevel 1 Trauma Centerin the region and has the only neonatal and pediatric intensive care units.

What You Will Do:

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

  • 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 morality 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 the coding workflow process and collaborates with the HIM coding department.

  • Prepares and presents educational sessions to physicians on proper documentation. Monitors and participates in performance improvement initiatives.

  • 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/conferneces/site visits where travel and overnight stay might be required.

  • Communicates effectively and adaptable to a wide variety of interpersonal environments with 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

What You Will Need:

Must demonstrate the ability to be credible to all clinical staff and communicate effectively both verbally and in written format Proficient knowledge of Microsoft applications, including Word, Excel and Powerpoint. Excellent communication and presentation skills are a must Knowledge of pathophysiology and disease process organizational, analytical, writing and interpersonal skills. Critical thinking, strong computer and customer services skills required.

  • Anatomy and Physiology Medical Terminology is required.

  • 5+ years of Clinical Documentation Specialist is preferred.

  • RHIA/RHIT is preferred.

  • CCS/CDS/ICD 10 is preferred.

  • Familiarity with Cerner and 3M applications.

License: RN certification is required. May consider physician trained experience.

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