Clin Document Spec (RN)

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Exemption Status:

Schedule Details:

Scheduled Hours:

Shift:

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Cost Center:

This position may have a signing bonus available a member of the Recruitment Team will confirm eligibility during the interview process.

Everyone Is a Caregiver

At UMass Memorial Health, everyone is a caregiver – 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. We are more than 16,000 employees, working together as one health system in a relentless pursuit of healing for our patients, community and each other. And everyone, in their own unique way, plays an important part, every day.

I. Major Responsibilities:

1. 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.
2. 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.
3. Communicates with attending physicians either verbally or electronically to validate observations and suggest additional and/or more specific documentation.
4. Supports Physician leaders with focused documentation reviews and special projects as directed.
5. Supports appropriate documentation for coding, reimbursement and quality purposes.   
6. Works closely, regularly and collaboratively with HIM Coding staff to ensure documentation of primary diagnoses and any co-existing conditions is a complete and accurate reflection of each patient’s clinical conditions in the context of coding requirements.
 

License/Certification/Education:
Required:
1. Massachusetts licensure as a registered nurse required
Preferred:
1. Bachelor’s degree preferred

Experience/Skills:
Required:
1. Experience in direct patient care, case management, utilization review or equivalent required.
2. Knowledge of clinical documentation practices and principles and ICD-10-CM diagnosis codes required.  
3. Excellent interpersonal skills and demonstrated ability to interact with physicians in a collaborative and professional manner. 
4. Ability to effectively use specialized computer based systems for gathering, reporting, and analyzing critical data.

Preferred:
1. 1-3 years of CDI experience preferred

Unless certification, licensure or registration is required, an equivalent combination of education and experience which provides proficiency in the areas of responsibility listed in this description may be substituted for the above requirements.

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.

We’re striving to make respect a part of everything we do at UMass Memorial Health – for our patients, our community and each other. Our six Standards of Respect are: Acknowledge, Listen, Communicate, Be Responsive, Be a Team Player and Be Kind. If you share these Standards of Respect, we hope you will join our team and help us make respect our standard for everyone, every day.

As an equal opportunity and affirmative action employer, UMass Memorial Health recognizes the power of a diverse community and encourages applications from individuals with varied experiences, perspectives and backgrounds. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sexual orientation, national origin, age, disability, gender identity and expression, protected veteran status or other status protected by law.

If you are unable to submit an application because of incompatible assistive technology or a disability, please contact us at talentacquisition@umassmemorial.org. We will make every effort to respond to your request for disability assistance as soon as possible.