Clinical Documentation Specialist

🕒 August 12

🗽 New York – Remote

🗽 New York – Remote

💵 $78k - $96.2k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🏥📝 Medical Writer

👻 Ghost score 37%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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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

• Review medical records for completeness and accuracy relating to severity of illness, risk of mortality, complexity of care, and quality • Conduct accurate and timely record reviews • Identify opportunities for documentation improvement • Formulate clinically credible documentation clarifications • Request clarifications for severity of illness, risk of mortality, complexity of care, core measures, and patient safety • Communicate effectively with physicians • Educate patient care team members about the CDS process • Follow up on cases and resolve clinical documentation clarifications • Participate actively in team meetings • Manage multiple priorities • Communicate with HIM staff and resolve discrepancies • Enter data accurately into department software • For Skilled Nursing Facility roles: apply ICD-10-CM coding guidelines and indexing systems; collaborate with hospital and SNF teams to support specified, appropriate, and billable diagnoses for SNF authorization and PDPM assessments

🎯 Requirements

• Registered nursing degree required; other clinical education may be considered, such as PA, NP, MD, or Foreign Medical Graduate (FMG) MD prepared • Active unrestricted RN license or other qualifying clinician status • At least 5 years of adult acute care experience in med/surg, critical care, emergency room, or PACU • CCDS or CDIP certification required within the stated eligibility timeline; effective 3 years from hire for CCDS certification • Current professional licensure in the State of New York based on degree • For Skilled Nursing Facility roles: 2–3 years’ experience with SNF payment methodologies and PDPM • Minimum 5 years short-term acute medical/surgical hospital nursing experience • Minimum 2 years CDI experience • Knowledge of payment methodologies and CMS/AHRQ quality metrics • Working knowledge of Epic EMR and Nuance CDE One • For Skilled Nursing Facility roles: knowledge of Medicare Part A guidelines, SNF PPS Final Rule, CMS Clinical Category Crosswalk, MDS RAI Manual, and CMS PDPM Calculator Tool