Clinical Document Specialist (RN)

UMass Memorial Health • San Jose, CA

7d • $87,277 - $157,082

About The Position

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. 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.

Requirements

• Massachusetts licensure as a registered nurse required
• Experience in direct patient care, case management, utilization review or equivalent required.
• 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.

Nice To Haves

• Bachelor’s degree preferred
• 1-3 years of CDI experience preferred

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.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 5,001-10,000 employees