What are the responsibilities and job description for the Lead Clinical Documentation Integrity Specialist position at Mass General Brigham?
Site: The Spaulding Rehabilitation Hospital Corporation
At Mass General Brigham, we know it takes a surprising range of talented professionals to advance our mission—from doctors, nurses, business people and tech experts, to dedicated researchers and systems analysts. As a not-for-profit organization, Mass General Brigham is committed to supporting patient care, research, teaching, and service to the community. We place great value on being a diverse, equitable and inclusive organization as we aim to reflect the diversity of the patients we serve.
At Mass General Brigham, we believe a diverse set of backgrounds and lived experiences makes us stronger by challenging our assumptions with new perspectives that can drive revolutionary discoveries in medical innovations in research and patient care. Therefore, we invite and welcome applicants from traditionally underrepresented groups in healthcare — people of color, people with disabilities, LGBTQ community, and/or gender expansive, first and second-generation immigrants, veterans, and people from different socioeconomic backgrounds – to apply.
Summary
Job Summary
This role supports the clinical documentation by providing leadership, guidance, training, and problem resolution to less experienced staff. This position is responsible for ensuring accurate documentation of patient conditions to improve care quality, compliance, and reimbursement. As a leader in this space, the role plays a key role in driving documentation best practices, serving as a compliance resource, and mentoring team members on effective, regulatory-compliant documentation.
Does this position require Patient Care?
No
Essential Functions
Education Associate's Degree Nursing required and Bachelor's Degree Nursing preferred Can this role accept experience in lieu of a degree? No Licenses and Credentials Registered Nurse [RN - State License] - Generic - HR Only preferred Experience Experience in clinical documentation improvement, medical coding, or a related area 3-5 years required and Experience as a lead, coordinator, or supervisor in clinical documentation 1-2 years preferred Knowledge, Skills and Abilities - Strong knowledge of clinical documentation standards, coding guidelines, and regulatory requirements. - Excellent analytical and problem-solving skills to assess and improve documentation practices. - Effective communication and interpersonal skills to collaborate with physicians, coders, and other staff. - Proficiency in health information systems and electronic medical record platforms. - Ability to provide education and training to clinical and administrative teams. - Detail-oriented with strong organizational skills to manage multiple tasks and meet deadlines.
Additional Job Details (if Applicable)
Physical Requirements
Remote
Work Location
399 Revolution Drive
Scheduled Weekly Hours
40
Employee Type
Regular
Work Shift
Day (United States of America)
EEO Statement
The Spaulding Rehabilitation Hospital Corporation is an Affirmative Action Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. 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.
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.
At Mass General Brigham, we know it takes a surprising range of talented professionals to advance our mission—from doctors, nurses, business people and tech experts, to dedicated researchers and systems analysts. As a not-for-profit organization, Mass General Brigham is committed to supporting patient care, research, teaching, and service to the community. We place great value on being a diverse, equitable and inclusive organization as we aim to reflect the diversity of the patients we serve.
At Mass General Brigham, we believe a diverse set of backgrounds and lived experiences makes us stronger by challenging our assumptions with new perspectives that can drive revolutionary discoveries in medical innovations in research and patient care. Therefore, we invite and welcome applicants from traditionally underrepresented groups in healthcare — people of color, people with disabilities, LGBTQ community, and/or gender expansive, first and second-generation immigrants, veterans, and people from different socioeconomic backgrounds – to apply.
Summary
Job Summary
This role supports the clinical documentation by providing leadership, guidance, training, and problem resolution to less experienced staff. This position is responsible for ensuring accurate documentation of patient conditions to improve care quality, compliance, and reimbursement. As a leader in this space, the role plays a key role in driving documentation best practices, serving as a compliance resource, and mentoring team members on effective, regulatory-compliant documentation.
Does this position require Patient Care?
No
Essential Functions
- Reviews and analyzes patient records to identify opportunities for improving clinical documentation.
- Provides education and guidance to physicians and clinical staff on documentation best practices and standards.
- Collaborates with coding and billing teams to ensure alignment between clinical documentation and coding requirements.
- Mentors, trains, and assists junior team members with day-to-day inquiries.
- Develops and implements strategies to address documentation gaps and improve accuracy.
- Conducts audits of medical records to monitor compliance and identify trends or areas for improvement.
- Prepares reports and presentations on documentation quality and outcomes for leadership and stakeholders.
- Serves as a resource for clinical staff on documentation policies, regulatory requirements, and hospital procedures.
- Participates in multidisciplinary meetings and initiatives to support continuous improvement in clinical documentation.
Education Associate's Degree Nursing required and Bachelor's Degree Nursing preferred Can this role accept experience in lieu of a degree? No Licenses and Credentials Registered Nurse [RN - State License] - Generic - HR Only preferred Experience Experience in clinical documentation improvement, medical coding, or a related area 3-5 years required and Experience as a lead, coordinator, or supervisor in clinical documentation 1-2 years preferred Knowledge, Skills and Abilities - Strong knowledge of clinical documentation standards, coding guidelines, and regulatory requirements. - Excellent analytical and problem-solving skills to assess and improve documentation practices. - Effective communication and interpersonal skills to collaborate with physicians, coders, and other staff. - Proficiency in health information systems and electronic medical record platforms. - Ability to provide education and training to clinical and administrative teams. - Detail-oriented with strong organizational skills to manage multiple tasks and meet deadlines.
Additional Job Details (if Applicable)
Physical Requirements
- Standing Occasionally (3-33%)
- Walking Occasionally (3-33%)
- Sitting Constantly (67-100%)
- Lifting Occasionally (3-33%) 20lbs - 35lbs
- Carrying Occasionally (3-33%) 20lbs - 35lbs
- Pushing Rarely (Less than 2%)
- Pulling Rarely (Less than 2%)
- Climbing Rarely (Less than 2%)
- Balancing Occasionally (3-33%)
- Stooping Occasionally (3-33%)
- Kneeling Rarely (Less than 2%)
- Crouching Rarely (Less than 2%)
- Crawling Rarely (Less than 2%)
- Reaching Occasionally (3-33%)
- Gross Manipulation (Handling) Constantly (67-100%)
- Fine Manipulation (Fingering) Frequently (34-66%)
- Feeling Constantly (67-100%)
- Foot Use Rarely (Less than 2%)
- Vision - Far Constantly (67-100%)
- Vision - Near Constantly (67-100%)
- Talking Constantly (67-100%)
- Hearing Constantly (67-100%)
Remote
Work Location
399 Revolution Drive
Scheduled Weekly Hours
40
Employee Type
Regular
Work Shift
Day (United States of America)
EEO Statement
The Spaulding Rehabilitation Hospital Corporation is an Affirmative Action Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. 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.
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.
