Clinical Document Specialist (RN)

About the role

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. Everyone is a caregiver – regardless of title or responsibilities. Exceptional patient care, academic excellence and leading-edge research make UMass Memorial Health the premier health system of Central Massachusetts, a place where you can build the career you deserve. With over 20,000 employees working together as one health system, we pursue healing for patients, community and each other. Everyone, in their own unique way, plays an important part every day.

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.

Requirements

• Massachusetts licensure as a registered nurse (required)
• Bachelor’s degree (preferred)
• Experience in direct patient care, case management, utilization review or equivalent (required)

Skills

• 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 (required)
• Ability to effectively use specialized computer based systems for gathering, reporting, and analyzing critical data (required)
• 1-3 years of CDI experience (preferred)

Benefits

• Position may have a signing bonus available; eligibility confirmed during the interview process.

Pay

Hiring range: $91,644.80 - $164,944.00 (based on a full‑time schedule of 40 hours per week). 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

Monday through Friday. Scheduled hours: 40 hrs per week. Shift: Day Shift, 8 Hours (United States of America).