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 #: 203528
Title: Clinical Documentation Specialist-RN
Department: Clinical Documents Specialists
 Posting Date: June 16,2020
Shift: Days
Status: Exempt
Hours: 40 hours
Shift Length: 8 hours
Location: UMass Memorial Health Care - University Campus

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:



Bachelor's degree preferred and 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.


1-3 years of CDI experience preferred.

Standards of Respect:

Standards of Respect
We’re striving to make respect a part of everything we do at UMass Memorial – for our patients and for each other. We’re expecting that our new caregivers practice our six Standards of Respect: Acknowledge, Listen, Communicate, Be Responsive, Be a Team Player, and Be Kind, to help us make respect a part of how we take care of business everyday.

As an equal opportunity and affirmative action employer, UMMHC 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.