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CLINICAL DOCUMENT SPECIALIST-RN

Company: UMass Memorial Health Care
Location: Worcester
Posted on: December 8, 2018

Job Description:

Requisition #: 190747

Title: Clinical Documentation Specialist-RN

Department: Revenue Cycle

Posting Date: November 21, 2018

Status: Exempt

Shift: Days

Hours: 40

Location: UMass Memorial Health Care -

UMass Memorial Health Care is the largest health care system in Central Massachusetts. We are the clinical partner of UMass Medical School, with access to the latest technology, research and clinical trials. Our health care system includes four hospitals:


  • UMass Memorial Medical Center (Worcester)
  • UMass Memorial HealthAlliance-Clinton Hospital (Clinton, Fitchburg and Leominster)
  • Marlborough Hospital (Marlborough)

    In addition to our fully equipped medical centers, our system also includes home health and hospice programs, behavioral health programs and community-based physician practices.

    Position Summary:

    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.

    Position Qualifications:

    Bachelor's degree preferred and Massachusetts licensure as a registered nurse required. Experience in direct patient care, case management, utilization review or equivalent required. 1-3 years of CDI experience preferred. 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.

    Major 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.

    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.

    Demonstrates and continues to develop a working knowledge of HIM Standards of coding and applies this knowledge to ongoing evaluation of medical record documentation.

    Develops and recommends corrective action for identified trends and opportunities for improvement.

    Develops and implements plans for both formal and informal education of physician, nursing, and other clinical staff. Prepares and presents educational materials to clinicians. Prepares and maintains written documentation aides (guidelines, tip cards, etc)

    Identifies strategies for sustained work process changes that facilitate complete, accurate clinical documentation.

    Maintains volume and quality of reviews consistent over time with peer Clinical Documentation Specialists and in-line with industry benchmarks adjusted for the UMass program as appropriate

    Complies with established departmental policies, procedures and objectives.

    Attends variety of meetings, conferences, seminars as required or directed.

    Demonstrates use of Quality Improvement in daily operations.

    Complies with all health and safety regulations and requirements.

    Respects diverse views and approaches, and contributes in maintaining an environment of professionalism, tolerance, civility and acceptance toward all employees, patients and visitors.

    Performs other similar and related duties as required or directed.

    All responsibilities are essential job functions.

    Keywords: UMass Memorial Health Care, Worcester , CLINICAL DOCUMENT SPECIALIST-RN, Healthcare , Worcester, Massachusetts

    Click here to apply!

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