Full Job Description
Job Summary
Responsible for improving clinical outcomes by managing, analyzing, and optimizing coding practices, clinical documentation, and healthcare transcription. Works closely with healthcare teams to ensure accurate documentation that supports patient care, quality initiatives, and regulatory compliance.
Does this position require Patient Care? No
-Reviews and monitors clinical documentation to ensure accuracy and completeness in coding and transcription practices.
-Collaborates with healthcare providers to improve documentation standards, aligning with best practices and regulatory requirements.
-Completes Inpatient Rehabilitation Facility (IRF-PAI) data, enters and transmits to CMS within federally mandated timeframes and organization policies for admissions and discharges (day 4 post-admit and day 3 post-discharge).
-Monitors and ensures correct LOA dates are recorded on the IRF PAI.
-Assures accurate Impairment Group Codes and co-morbidities in collaboration with coding and CDI staff to determine the correct length of stay estimate and CMG in adherence with CMS IRF Coding standards.
-Communicates ELOS to clinical staff to assist with care/discharge planning.
-Analyzes clinical data to identify trends, track patient outcomes, and assess areas for improvement in clinical documentation.
-Implements training programs for clinical staff on accurate documentation, coding, and transcription standards.
-Coordinates with quality improvement teams to support accurate data collection for performance metrics and patient safety initiatives.
-Assesses clinical documentation for compliance with coding standards, ensuring proper billing and regulatory adherence.
-Prepares detailed reports on clinical outcomes and documentation effectiveness for internal audits and external reporting.
Qualifications
Education
Associate's Degree Related Field of Study required or
Master's Degree Occupational Therapy required or
Master's Degree Speech Therapy required or
Doctor of Physical Therapy Physical Therapy required
Can this role accept experience in lieu of a degree? No
Licenses and Credentials
Registered Nurse [RN - Massachusetts License] - preferred
Speech-language Pathologist [Massachusetts License] - preferred
Physical Therapist [Massachusetts License] - preferred
Occupational Therapist [Massachusetts License] - preferred
Experience
Experience managing documentation quality or coding 1-2 years required and Previous Occupational Therapy, Physical Therapy, Speech Therapy or Registered Nurse experience 2-3 years required
Knowledge, Skills and Abilities
- Expert knowledge of clinical documentation practices and coding standards.
- Strong analytical skills for data review and outcomes reporting.
- Excellent communication skills for interacting with clinical teams and providing documentation training.
- Proficiency in using electronic health records (EHR) systems.
- Attention to detail and ability to manage compliance requirements effectively.
Additional Job Details (if applicable)
Remote Type
Hybrid
Work Location
311 Service Road
Scheduled Weekly Hours
40
Employee Type
Regular
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.
