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

UMass Memorial Health in Worcester, MA is seeking a CDI Nurse Specialist to ensure complete and accurate medical record documentation across patient care.

You will collaborate with physicians, nurses and care teams to identify documentation gaps, support coding, reimbursement and quality initiatives, and participate in process improvements.

Qualifications

• Massachusetts licensure as a registered nurse is required.
• Bachelor's degree is preferred.

Responsibilities

• Collaborate with physicians, nurses and staff to ensure accurate medical record documentation.
• Review inpatient medical records for identified payer populations or clinical specialties; analyze clinical status and history to identify gaps in documentation.
• Communicate with attending physicians to validate observations and suggest additional or more specific documentation.
• Support physician leaders with focused documentation reviews and special projects as directed.
• Support documentation for coding, reimbursement and quality purposes.

Skills

Direct patient care

Case management

Utilization review

ICD-10-CM

Interpersonal skills

Data analysis

CDI experience

Education

Massachusetts nursing license

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.
• 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 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.