Clin Document Spec (RN) at UMass Memorial Health

Are you an internal caregiver student or contingent worker/agency worker at UMass Memorial Health CLICK HERE to apply through your Workday account.Exemption Status:ExemptHiring Range:$87276.80 - $157081.60Please note that the final offer may vary within this range based on a candidates experience skills qualifications and internal equity considerations.Schedule Details:Monday through FridayScheduled Hours:8:00 am - 4:30 pmShift:1 - Day Shift 8 Hours (United States of America)Hours:40Cost Center:99940 - 5401 Clinical Documents SpecialistsThis position may have a signing bonus available a member of the Recruitment Team will confirm eligibility during the interview process.Everyone Is a CaregiverAt 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 20000 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.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.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 patients clinical conditions in the context of coding requirements.License/Certification/Education:Required:1. Massachusetts licensure as a registered nurse requiredPreferred:1. Bachelors degree preferredExperience/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 preferredUnless 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.Were 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 We will make every effort to respond to your request for disability assistance as soon as possible. Key Skills B2C,Facilities Management,Ado,Bus Driving,Application Support,Arabic Cuisine Employment Type : Full-Time Experience: years Vacancy: 1 Monthly Salary Salary: 87276 - 157081