Clinical Documentation Specialist

🕒 August 12

🗽 New York – Remote

🗽 New York – Remote

💵 $78k - $96.2k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🏥📝 Medical Writer

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Rochester Regional Health

WebsiteLinkedInAll Job Openings

10,000+ employees

🏥 Healthcare

⚕️ Healthcare Insurance

📚 Education

Healthcare • Healthcare Insurance • Education

Rochester Regional Health is an integrated health services organization serving the people of Western New York. It operates multiple hospitals and healthcare facilities, providing a wide range of healthcare services, including emergency care, primary care, specialty clinics, and urgent care. The organization is committed to medical education and research, offering training programs, residencies, and clinical trials. Rochester Regional Health focuses on comprehensive care with emphasis on treating patients respectfully and meeting their diverse medical needs across all stages of life.

📋 Description

• Facilitate accurate documentation for severity of illness, expected risk of mortality, complexity of care, and quality in medical records • Review medical records for completeness and accuracy • Identify opportunities for documentation improvement • Formulate and request clinically credible documentation clarifications • Communicate effectively with physicians and healthcare and ancillary teams • Educate patient care team members about the CDS process • Follow up on cases and resolve clinical documentation clarifications • Participate in team meetings and manage multiple priorities • Communicate with HIM staff and resolve discrepancies • Enter data accurately into department software • For Skilled Nursing Facility: apply ICD-10-CM coding guidelines and indexing systems • For Skilled Nursing Facility: collaborate with hospital and SNF teams to support specified, appropriate, and billable ICD-10-CM codes and PDPM assessments

🎯 Requirements

• Registered nursing degree required; other clinical education may be considered, including PA, NP, MD, or FMG MD preparation • Active unrestricted RN or other qualifying clinician status with at least 5 years of adult acute care experience in med/surg, critical care, emergency room, or PACU, effective 03/02/2026 • CCDS or CDIP certification exam required within six months of eligibility if not certified; CCDS certification required three years from hire, effective 03/02/2026 • For Skilled Nursing Facility: 2–3 years of experience with SNF payment methodologies and PDPM, effective 03/02/2026 • Current professional licensure in New York State based on degree; FMG MD-prepared license not required • Minimum 5 years of short-term acute medical/surgical hospital nursing experience • Minimum 2 years of CDI experience • Knowledge of payment methodologies and CMS/AHRQ quality metrics • Working knowledge of Epic EMR and Nuance CDE One • For Skilled Nursing Facility: knowledge of Medicare Part A guidelines, SNF PPS Final Rule, CMS Clinical Category Crosswalk, MDS RAI Manual, and CMS PDPM Calculator Tool • Sedentary work capability, including occasional exertion of up to 10 pounds of force