Clinical Documentation Specialist - CDI & Patient Care

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

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.