Clinical Documentation Specialist Jobs in Massachusetts
Clinical Documentation Specialist jobs in Massachusetts are consistently active, with strong demand driven by the state's dense concentration of academic medical centers, large integrated health systems, and specialty hospitals, at levels from entry-level coders through senior CDI consultants. Boston, Worcester, and Springfield anchor most of the hiring, with major employers such as Mass General Brigham, Beth Israel Deaconess Medical Center, and UMass Memorial Health maintaining ongoing CDI needs. Inpatient clinical documentation, risk adjustment, and query management are the most sought-after specialties across Massachusetts listings. Find a role that fits below and apply directly.
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Showing 5 of 7+ Clinical Documentation Specialist jobs
Improve Patient Care. Strengthen Documentation. Drive Impact.
About the Role
We’re seeking a detail-oriented and collaborative Clinical Documentation Specialist (CDS) to join our Medical Records team. In this role, you will help ensure the accuracy, completeness, and integrity of clinical documentation—supporting high-quality patient care, regulatory compliance, and appropriate reimbursement.
Reporting to the Manager, Clinical Documentation & Coding, you will work closely with physicians, nurses, and interdisciplinary teams to ensure documentation reflects the full clinical picture. In this role, you will perform concurrent reviews of inpatient medical records to identify documentation gaps and opportunities to enhance the quality and accuracy of physician documentation.
If you thrive in a fast-paced clinical environment and enjoy combining clinical expertise with problem-solving and collaboration, this is a great opportunity to make a meaningful impact.
What You’ll Do
- Review medical records to ensure accurate, complete, and compliant clinical documentation
- Collaborate with physicians and care teams to clarify and improve documentation quality
- Apply clinical and coding knowledge to support accurate code assignment and reimbursement
- Facilitate documentation improvement initiatives in both concurrent and retrospective reviews
- Educate providers and care teams on CMS regulations, documentation standards, and best practices
- Partner with coding professionals to ensure alignment between documentation and coding outcomes
- Support quality, compliance, and continuous improvement initiatives across the organization
What You Bring
Education
- Bachelor of Science in Nursing (BSN) or Bachelor of Science in Biology or a related healthcare clinical program (e.g., Medical Records/Health Information Management)
Experience
- One of the following:
- 3–5 years of acute care or equivalent clinical experience, or
- 3+ years of inpatient coding experience
Licensure & Certification
- Current Massachusetts Registered Nurse (RN) license and/or
- AHIMA coding certification (e.g., CCS, RHIT, RHIA) required
Skills & Competencies
- Ability to work independently and manage responsibilities with minimal supervision
- Strong verbal and written communication skills
- Proven ability to build effective working relationships with a wide range of healthcare providers
- Team-oriented mindset with strong collaboration and information-sharing skills
- Critical thinking and problem-solving abilities in complex clinical scenarios
- Strong organizational skills with the ability to stay focused despite frequent interruptions
- Proficiency with computer systems and ability to quickly learn new software applications
- Effective time management skills, with the ability to prioritize multiple tasks and meet deadlines
- Ability to interpret medical record documentation, prepare reports, and communicate findings clearly
- Comfort working with basic mathematical concepts such as percentages, ratios, and data analysis
- Knowledge of DPH regulations, Medicare/CMS rules and regulations
- Understanding of Joint Commission standards and continuous quality improvement (CQI) processes
- Commitment to maintaining strict confidentiality of patient and organizational information
Why Join Us?
- Make a direct impact on patient care quality and outcomes
- Collaborate with a dedicated, interdisciplinary healthcare team
- Expand your expertise in clinical documentation, compliance, and healthcare quality
- Competitive compensation and comprehensive benefits
Location: Emerson Hospital · Medical Records
Schedule: Full Time, Day shift, 7am-3:30pm
Improve Patient Care. Strengthen Documentation. Drive Impact.
About the Role
We’re seeking a detail-oriented and collaborative Clinical Documentation Specialist (CDS) to join our Medical Records team. In this role, you will help ensure the accuracy, completeness, and integrity of clinical documentation—supporting high-quality patient care, regulatory compliance, and appropriate reimbursement.
Reporting to the Manager, Clinical Documentation & Coding, you will work closely with physicians, nurses, and interdisciplinary teams to ensure documentation reflects the full clinical picture. In this role, you will perform concurrent reviews of inpatient medical records to identify documentation gaps and opportunities to enhance the quality and accuracy of physician documentation.
If you thrive in a fast-paced clinical environment and enjoy combining clinical expertise with problem-solving and collaboration, this is a great opportunity to make a meaningful impact.
What You’ll Do
- Review medical records to ensure accurate, complete, and compliant clinical documentation
- Collaborate with physicians and care teams to clarify and improve documentation quality
- Apply clinical and coding knowledge to support accurate code assignment and reimbursement
- Facilitate documentation improvement initiatives in both concurrent and retrospective reviews
- Educate providers and care teams on CMS regulations, documentation standards, and best practices
- Partner with coding professionals to ensure alignment between documentation and coding outcomes
- Support quality, compliance, and continuous improvement initiatives across the organization
What You Bring
Education
- Bachelor of Science in Nursing (BSN) or Bachelor of Science in Biology or a related healthcare clinical program (e.g., Medical Records/Health Information Management)
Experience
- One of the following:
- 3–5 years of acute care or equivalent clinical experience, or
- 3+ years of inpatient coding experience
Licensure & Certification
- Current Massachusetts Registered Nurse (RN) license and/or
- AHIMA coding certification (e.g., CCS, RHIT, RHIA) required
Skills & Competencies
- Ability to work independently and manage responsibilities with minimal supervision
- Strong verbal and written communication skills
- Proven ability to build effective working relationships with a wide range of healthcare providers
- Team-oriented mindset with strong collaboration and information-sharing skills
- Critical thinking and problem-solving abilities in complex clinical scenarios
- Strong organizational skills with the ability to stay focused despite frequent interruptions
- Proficiency with computer systems and ability to quickly learn new software applications
- Effective time management skills, with the ability to prioritize multiple tasks and meet deadlines
- Ability to interpret medical record documentation, prepare reports, and communicate findings clearly
- Comfort working with basic mathematical concepts such as percentages, ratios, and data analysis
- Knowledge of DPH regulations, Medicare/CMS rules and regulations
- Understanding of Joint Commission standards and continuous quality improvement (CQI) processes
- Commitment to maintaining strict confidentiality of patient and organizational information
Why Join Us?
- Make a direct impact on patient care quality and outcomes
- Collaborate with a dedicated, interdisciplinary healthcare team
- Expand your expertise in clinical documentation, compliance, and healthcare quality
- Competitive compensation and comprehensive benefits
Location: Emerson Hospital · Medical Records
Schedule: Full Time, Day shift, 7am-3:30pm
See All 7 Clinical Documentation Specialist Jobs in Massachusetts
Find roles in Massachusetts that match your experience and apply in just a few clicks.
Find JobsClinical Documentation Specialist Jobs by City in Massachusetts
Where Massachusetts roles are concentrated, by current openings.
Clinical Documentation Specialist Job Market in Massachusetts
A snapshot from current Massachusetts openings, updated as new roles post.
Who's Hiring
Top Industries Hiring
- Healthcare & Medical Services
- Biotechnology & Pharmaceuticals
What Massachusetts Employers Look For
The qualifications that appear most often in clinical documentation specialist jobs across Massachusetts.
- Registered Health Information Technician or Administrator credential (RHIT or RHIA) preferred by Massachusetts employers
- Clinical Documentation Improvement Practitioner (CDIP) or Certified Clinical Documentation Specialist (CCDS) certification strongly preferred
- Minimum two years of inpatient coding, CDI, or clinical nursing experience in an acute care setting
- Proficiency with ICD-10-CM and ICD-10-PCS coding guidelines as applied in Massachusetts hospital systems
- Experience using electronic health record platforms such as Epic or Meditech, widely deployed across Massachusetts facilities
- Strong written communication skills to compose compliant clinical queries directed to attending physicians
Clinical Documentation Specialist Jobs in Massachusetts: Frequently Asked Questions
How do you become a clinical documentation specialist in Massachusetts?
Most clinical documentation specialists in Massachusetts enter the field through one of two paths: completing an accredited health information management program leading to an RHIT or RHIA credential, or transitioning from a clinical background such as registered nursing combined with CDI training. Massachusetts does not issue a separate state license for this role, but employers consistently require the CDIP credential offered by the American Health Information Management Association or the CCDS credential offered by the Association of Clinical Documentation Integrity Specialists before or shortly after hire.
How much do clinical documentation specialists make in Massachusetts?
Clinical documentation specialists in Massachusetts earn a median of about $60,350 a year, based on May 2025 Bureau of Labor Statistics wage data, ranging from around $43,960 for the lowest 10% to over $81,620 for the top 10%. Pay rises with experience, specialty, and employer.
Which companies hire clinical documentation specialists in Massachusetts?
Employers hiring clinical documentation specialists in Massachusetts right now include Beth Israel Lahey Health, FutureSight, and Emerson Hospital, based on current listings on Migrate Mate as of August 2026. Massachusetts's high density of academic medical centers and large integrated networks means CDI openings appear regularly across both inpatient hospital and physician group settings throughout the state.
Which Massachusetts cities have the most clinical documentation specialist jobs?
Boston, Burlington, and Concord have the most clinical documentation specialist openings in Massachusetts. Boston dominates because of its concentration of world-class academic medical centers and large integrated health systems, while Worcester and Springfield generate consistent openings through regional hospital networks like UMass Memorial Health and Baystate Health, which operate multiple acute care facilities in those metro areas.
Are there remote clinical documentation specialist jobs in Massachusetts?
Yes, and more than most clinical roles, because the work centers on reviewing electronic health records and drafting physician queries rather than direct patient care. About 100% of clinical documentation specialist openings tied to Massachusetts are remote or hybrid as of August 2026, reflecting how fully the field has moved to electronic documentation. Query management and concurrent review roles are the functions most commonly performed remotely.
How can I get hired as a clinical documentation specialist in Massachusetts with little or no experience?
The most realistic entry path is lateral transition from a clinical or health information role: registered nurses, medical coders, and health information technicians at Massachusetts systems like Mass General Brigham and Beth Israel Deaconess Medical Center routinely move into CDI associate or trainee positions. Completing an AHIMA-approved coding or health information management program and earning an RHIT credential before applying gives candidates a concrete edge, as does familiarity with Epic, which is the dominant EHR platform at most large Massachusetts employers.
Where can I find and apply to clinical documentation specialist jobs in Massachusetts?
You can find and apply to clinical documentation specialist jobs in Massachusetts on Migrate Mate, which lists current Massachusetts openings updated regularly. Find the roles that fit your background and apply directly from each listing.
See All 7 Clinical Documentation Specialist Jobs in Massachusetts
Find roles in Massachusetts that match your experience and apply in just a few clicks.
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