Clinical Document Specialist (RN)

Umass-Memorial-Health-; Worcester (MA); On-site; USD 92,000 - 165,000; Full time

Benefits offered by this job

Signing bonus

Job summary

URIs: UMass Memorial Health seeks a Clinical Documentation Specialist (RN) to ensure accurate medical record documentation reflecting patient severity and complexity. You will collaborate with physicians and care teams to improve documentation for coding and quality.

The role requires MA RN licensure, CDI familiarity, and strong communication with clinicians. The position is based in Worcester with a 40-hour work week in a day shift.

Qualifications

• Massachusetts RN license required.
• Experience in direct patient care, case management, or utilization review required.
• Knowledge of ICD-10-CM codes and clinical documentation practices.
• Excellent interpersonal skills to interact with physicians professionally.
• Ability to use specialized computer-based systems for data gathering and reporting.

Responsibilities

• Document accurate medical records reflecting severity of illness and risk of mortality.
• Review inpatient records for identified payer populations and clinical specialties throughout hospitalization.
• Collaborate with attending physicians to validate observations and improve documentation; support coding, reimbursement and quality goals.

Skills

Direct patient care

Case management

Utilization review

Interpersonal skills

Communication with physicians

ICD-10-CM knowledge

Education

Massachusetts RN license

Bachelor’s degree (preferred)

Tools

Clinical documentation systems

Job description

Are you an internal caregiver, student, or contingent worker/agency worker at UMass Memorial Health? CLICK HERE to apply through your Workday account.Exemption Status:ExemptHiring 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 FridayScheduled Hours:40 hrsShift:1 - Day Shift, 8 Hours (United States of America)Hours:40Cost Center:99940 - 5401 Clinical Documents SpecialistsThis position may have a signing bonus available a member of the Recruitment Team will confirm eligibility during the interview process.Everyone Is a CaregiverAt 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 requiredPreferred:Bachelor’s degree preferredExperience/Skills:Required:Experience in direct patient care, case management, utilization review or equivalent required.Knowledge of clinical documentation practices and principles and ICD-10-CM diagnosis codes required.Excellent interpersonal skills and demonstrated ability to interact with physicians in a collaborative and professional manner.Ability to effectively use specialized computer based systems for gathering, reporting, and analyzing critical data.Preferred:1-3 years of CDI experience preferredAll 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.