Clinical Document Specialist, RN

This is a fully remote position, open to applicants in Massachusetts.

📋 Description

• Utilize clinical expertise and experience to work in collaboration with physicians and other team members.

• Ensure that patient records accurately reflect the status, complexity, and intensity of patient conditions and care.

• Review inpatient medical records for specific payer populations or clinical specialties upon admission and throughout the hospitalization process.

• Analyze the clinical status of patients, current treatment plans, and past medical histories to identify potential gaps in physician documentation.

• Engage in communication with attending physicians, either verbally or electronically, to confirm observations and recommend additional documentation.

• Assist Physician leaders with targeted documentation reviews and special projects.

⛳️ Requirements

• A valid Massachusetts licensure as a registered nurse is required.

• Required experience in direct patient care, case management, utilization review, or a related field.

• Required knowledge of clinical documentation practices and principles, as well as ICD-10-CM diagnosis codes.

• Outstanding interpersonal skills with a proven ability to interact with physicians in a collaborative and professional manner.

• Proficient in utilizing specialized computer-based systems for collecting, reporting, and analyzing critical data.

• Preferred: 1-3 years of experience in Clinical Documentation Improvement (CDI).

🏝️ Benefits

• This position may offer a signing bonus.

• Benefits include exceptional patient care, academic excellence, and cutting-edge research opportunities.

• Flexible scheduling options are available.