Clinical Documentation Review RN

Fallon Health • Worcester, MA

2d • $110,000 - $115,000

About The Position

The Clinical Documentation Review RN is responsible for auditing care plans, health risk assessments, MDS assessments and other clinical documentation to ensure accuracy, completeness, and compliance. This role supports quality of care and regulatory adherence by reviewing documentation against CMS and state contractual guidelines. The reviewer provides feedback and guidance to clinical teams to promote accurate, consistent and compliant documentation that reflects the member’s health status and care needs.

Requirements

• Graduate from an accredited school of nursing
• Active, unrestricted license as a Registered Nurse in Massachusetts
• Satisfactory Criminal Offender Record Information (CORI) results
• Reliable transportation
• 4+ years job experience as a Registered Nurse working in a care management/care coordination role in a managed care payor operating a dual Special Needs Plan required.
• Experience with NCQA, CMS, and other required regulatory requirements and experience writing and developing policies and process documents required.
• Ability to develop a system and process to objectively measure care management competencies and to hold team members accountable, including, but not limited to developing corrective action plans, as appropriate
• Ability to identify gaps in staff’s knowledge base and to design training materials to address those gaps
• Ability to teach others in an organized and structured manner utilizing adult learning principles and collaboration skills
• Advanced skills in software systems including but not limited to Microsoft Office Products – Excel, Outlook, and Word
• Working with an interdisciplinary care team as a partner demonstrating respect and value for all roles and is a positive contributor within job role scope and duties
• Knowledgeable about medical record documentation
• Critical thinking skills for independent problem solving
• Access and ability to navigate the State’s Virtual Gateway platform for MDS-HC review and submission
• Excellent attention to detail, analytical skills, and ability to identify discrepancies in documentation.
• Proficiency with EMR systems and audit tools.
• Strong written and verbal communication skills; ability to provide constructive feedback to clinical staff.
• Strong knowledge and understanding of current State Supplemental Instructions for MDS-HC submission for rating category assignment

Nice To Haves

• Bachelors (or advanced) degree in nursing or a health care related field preferred
• Certification in Case Management preferred
• Experience with developing audit tools, auditing team member performance, and working with staff to improve their performance preferred.
• Manipulation of Excel spreadsheets to manage work and exposure and familiarity with pivot tables desirable
• Prior experience with clinical documentation review, quality audits, or utilization review preferred.
• Familiarity with chronic disease management, care planning and transitions of care.
• Experience with Minimum Data Set- Home Care assessments and requirements associated with such.

Responsibilities

• Audits documentation ensuring documentation meets quality standards and interventions and actions are effective to meet member needs
• Conduct audits of medical records to verify that documentation supports the services provided, meets regulatory standards, and aligns with SCO program requirements.
• Ensure interdisciplinary care plans are updated and reflect current member needs and are in compliance with regulatory and accreditation requirements.
• Confirm that assessments are documented and integrated into care planning.
• Audit MDS-HC forms entered into the State’s System to ensure compliance with current Supplemental Instructions
• Audit documentation for evidence of care coordination across medical, behavioral health, and long-term services.
• Ensure transitions of care (e.g., hospital discharge) are documented with follow-up plans and communication between providers.
• Identify documentation gaps that may impact care coordination, reimbursement, or compliance with MassHealth, CMS, and SCO-specific guidelines.
• Collaborate with providers and care teams to clarify clinical documentation through queries and feedback, ensuring accurate reflection of patient acuity, diagnoses, and care plans.
• Monitor trends and patterns in documentation errors or omissions and recommend corrective actions or process improvements.
• Educate clinical staff on best practices for documentation, including SCO-specific standards, regulatory updates, and audit findings.
• Participate in interdisciplinary and team meetings to provide insight into documentation quality and contribute to care planning and compliance strategies.
• Maintain audit logs and reports to track findings, follow-up actions, and performance metrics related to documentation quality and integrity.
• Collaborate with departments throughout Fallon to ensure documentation aligns with company policies and procedures.

Benefits

• Fallon Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior