Clinical Documentation Specialist (RN)

Finance & Revenue Cycle Worcester, Massachusetts


Position at UMass Memorial Health Care

Everyone Is a Caregiver.

At UMass Memorial Health Care, Everyone is a Caregiver regardless of title. Exceptional patient care, academic excellence and leading-edge research make UMass Memorial the premier health care system of Central and Western Massachusetts, and a place where we can help you build the career you deserve. We are more than 14,000 employees, working together as one health care system. And everyone, in their own unique way, plays an important part, everyday.

Requisition #: 213804

Title: Clinical Documentation Specialist-RN

Department: Revenue Cycle

Posting Date: April 14, 2021

Status: Exempt

Shift: Days

Hours: 40

Location: UMass Memorial Medical Center – University

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.

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.

Position Qualifications:



  • Massachusetts licensure as a registered nurse required


  • Bachelor’s degree preferred



  • 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.


  • 1-3 years of CDI experience preferred

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.

Standards of Respect: