UMass Memorial Health is hiring a Clinical Documentation Specialist (RN) to ensure medical records are accurate and complete, reflecting patient care complexity. In this remote role, you will collaborate closely with physicians and staff to support documentation for coding, reimbursement, and quality purposes.
What You'll Do
- Collaborate with physicians, nurses, and staff to ensure accurate medical record documentation reflects severity of illness.
- Review inpatient medical records upon admission and throughout hospitalization for identified populations.
- Analyze patient clinical status, treatment plans, and history to identify potential gaps in physician documentation.
- Communicate with attending physicians to validate observations and suggest more specific documentation.
- Support Physician leaders with focused documentation reviews and special projects.
- Support appropriate documentation for coding, reimbursement, and quality purposes.
What We're Looking For
- Massachusetts licensure as a registered nurse.
- Experience in direct patient care, case management, utilization review, or equivalent.
- Knowledge of clinical documentation practices and principles and ICD-10-CM diagnosis codes.
- Excellent interpersonal skills and demonstrated ability to interact with physicians collaboratively.
- Ability to effectively use specialized computer-based systems for gathering, reporting, and analyzing critical data.
Nice to Have
- Bachelor’s degree.
- 1-3 years of Clinical Documentation Improvement (CDI) experience.
Technical Stack
- Specialized computer-based systems for gathering, reporting, and analyzing critical data.
Benefits & Compensation
- This position may have a signing bonus available.
Work Mode
This is a fully remote position.
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.
