Clinical Documentation Specialist (RN)
Requisition #: 203528
Title: Clinical Documentation Specialist-RN
Department: Clinical Documents Specialists
Posting Date: June 16,2020
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.
- 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.
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.
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