Clinical Document Specialist (RN)

About the role

Everyone is a caregiver at UMass Memorial Health – 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.

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.

Qualifications

• Massachusetts licensure as a registered nurse 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.

Benefits

Final offer may vary within this range based on a candidate’s 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)

Cost Center: 99940 - 5401 Clinical Documents Specialists

Pay

Hiring Range: $91,644.80 - $164,944.00

Schedule

Shift: 1 - Day Shift, 8 Hours (United States of America)

Hours: 40