Clinical Documentation Specialist (RN)-REMOTE

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 20,000 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. 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.

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.