Remote Clinical Documentation Specialist (RN)

HAHHH; Worcester, Northern (MA, KY); Hybrid; USD 92,000 - 165,000; Full time

Job summary

UMass Memorial Health is seeking a Clinical Document Specialist (RN) to work primarily remotely, with a base in Worcester, MA. The role focuses on accurate medical record documentation and collaboration with physicians to ensure appropriate coding and reimbursement.

Full-time, day shift, 40 hours per week, with a competitive range and potential signing bonus. The position requires MA RN licensure, preferred bachelor’s degree, and CDI experience.

Qualifications

• Massachusetts licensure as a registered nurse is required.
• Bachelor’s degree preferred.
• Experience in direct patient care, case management, utilization review or equivalent.
• Knowledge of clinical documentation practices and ICD-10-CM codes.
• Excellent interpersonal skills and ability to interact with physicians and staff.
• Proficiency with computer-based systems for gathering, reporting, and analyzing data.

Responsibilities

• Works collaboratively with physicians, nurses, and staff to ensure accurate and complete medical record documentation reflecting severity of illness and risk of mortality.
• Reviews inpatient medical records for identified payer populations or clinical specialties on admission and during hospitalization.
• Analyzes clinical status, treatment plan, and history to identify documentation gaps.
• Communicates with attending physicians to validate observations and suggest additional documentation.
• Supports documentation for coding, reimbursement, and quality purposes.

Skills

Interpersonal skills

Data systems literacy

Documentation practices knowledge

ICD-10-CM knowledge

Education

Massachusetts RN licensure

Bachelor’s degree preferred

Job description

UMass Memorial Health is seeking a Clinical Document Specialist (RN) to work primarily remotely, with a base in Worcester, MA. The role focuses on accurate medical record documentation and collaboration with physicians to ensure appropriate coding and reimbursement.

Full-time, day shift, 40 hours per week, with a competitive range and potential signing bonus. The position requires MA RN licensure, preferred bachelor’s degree, and CDI experience.