Clinical Document Specialist (RN)

ummh; Worcester (MA); On-site; USD 92,000 - 165,000; Full time

Benefits offered by this job

Signing bonus potential

Job summary

UMass Memorial Health is seeking a Clinical Documents Specialist to ensure complete and accurate medical record documentation. This role closely collaborates with physicians and care teams to verify illness severity, risk of mortality, and coding readiness.

Required MA RN licensure with direct patient care experience; CDI knowledge and strong interpersonal skills are essential. A signing bonus may be available during interviews; 40-hour work week, day shift, in Central Massachusetts.

Qualifications

• Massachusetts RN license is required.
• Experience in direct patient care, case management, utilization review or equivalent.
• Knowledge of clinical documentation practices and ICD-10-CM coding.

Responsibilities

• Collaborate with physicians and staff to ensure complete medical record documentation.
• Review inpatient records for payer populations and clinical specialties.
• Analyze patient status, treatment plan and history to identify documentation gaps.
• Communicate observations to attending physicians to validate and suggest updates.
• Support documentation reviews for coding, reimbursement and quality.

Skills

RN license

Documentation skills

Clinical documentation

Interpersonal skills

ICD-10-CM coding knowledge

Education

Bachelor's degree preferred

Job description

Exemption Status: Exempt Hiring Range: $91,644.80 - $164,944.00 (based on a full time schedule of 40 hours per week). Please note that the final offer will vary based on scheduled hours. Compensation for part-time or reduced schedules will be prorated based on scheduled weekly hours, experience, skills, qualifications, and internal equity considerations.

Schedule Details: Monday through Friday Scheduled Hours: 40 hrs Shift: 1 - Day Shift, 8 Hours (United States of America) Hours: 40 Cost Center: 99940 - 5401 Clinical Documents Specialists This position may have a signing bonus available a member of the Recruitment Team will confirm eligibility during the interview process.

Everyone Is a Caregiver At UMass Memorial Health, everyone is a caregiver - regardless of their title or responsibilities. Exceptional patient care, academic excellence and leading-edge research make UMass Memorial the premier health system of Central Massachusetts, and a place where we can help you build the career you deserve. We are more than 20,000 employees, working together as one health system in a relentless pursuit of healing for our patients, community and each other. And everyone, in their own unique way, plays an important part, every day.

Drawing upon clinical knowledge and experience, closely collaborates with physicians and other team members to ensure that patient records accurately document the status, complexity and intensity of patient conditions and care.

Drawing upon clinical knowledge and experience, closely collaborates with physicians and other team members to ensure that patient records accurately document the status, complexity and intensity of patient conditions and care.

Major Responsibilities:

• Works collaboratively with physicians, nurses, and other staff to ensure accurate and complete medical record documentation to appropriately reflect severity of illness and risk of mortality.
• Reviews inpatient medical records for identified payer populations or clinical specialties upon admission and throughout hospitalization. Analyzes clinical status of patient, current treatment plan and past medical history and identifies potential gaps in physician documentation.
• Communicates with attending physicians either verbally or electronically to validate observations and suggest additional and/or more specific documentation.
• Supports Physician leaders with focused documentation reviews and special projects as directed.
• Supports appropriate documentation for coding, reimbursement and quality purposes.

Position Qualifications:

• License/Certification/Education:
  • Required: Massachusetts licensure as a registered nurse required
  • Preferred: Bachelor's degree preferred
• Experience/Skills:
  • Required: Experience in direct patient care, case management, utilization review or equivalent required.
  • Required: Knowledge of clinical documentation practices and principles and ICD-10-CM diagnosis codes required.
  • Required: Excellent interpersonal skills and demonstrated ability to interact with physicians in a collaborative and professional manner.
  • Required: Ability to effectively use specialized computer based systems for gathering, reporting, and analyzing critical data.
  • Preferred: 1-3 years of CDI experience preferred

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status.

We're striving to make respect a part of everything we do at UMass Memorial Health - for our patients, our community and each other. Our six Standards of Respect are: Acknowledge, Listen, Communicate, Be Responsive, Be a Team Player and Be Kind. If you share these Standards of Respect, we hope you will join our team and help us make respect our standard for everyone, every day.

As an equal opportunity and affirmative action employer, UMass Memorial Health recognizes the power of a diverse community and encourages applications from individuals with varied experiences, perspectives and backgrounds. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sexual orientation, national origin, age, disability, gender identity and expression, protected veteran status or other status protected by law.

If you are unable to submit an application because of incompatible assistive technology or a disability, please contact us at [e-mail]. We will make every effort to respond to your request for disability assistance as soon as possible.