Clinical Documentation Specialist

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

📋 Description

• Ensure precise documentation regarding the severity of illness, anticipated mortality risk, complexity of care, and quality within medical records.

• Assess medical records for thoroughness and accuracy.

• Recognize areas for enhancement in documentation.

• Develop and solicit clinically valid documentation clarifications.

• Communicate effectively with physicians, healthcare teams, and ancillary staff.

• Provide education to patient care team members regarding the Clinical Documentation Specialist (CDS) process.

• Follow up on cases and address clinical documentation clarifications.

• Engage in team meetings while managing multiple priorities.

• Coordinate with Health Information Management (HIM) staff to rectify discrepancies.

• Accurately input data into departmental software.

• For Skilled Nursing Facility: implement ICD-10-CM coding guidelines and indexing systems.

• For Skilled Nursing Facility: collaborate with hospital and SNF teams to ensure appropriate, specified, and billable ICD-10-CM codes and PDPM assessments.

⛳️ Requirements

• A registered nursing degree is mandatory; other clinical qualifications may be considered, including PA, NP, MD, or FMG MD preparation.

• Active unrestricted RN or equivalent clinician status with a minimum of 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 must be completed within six months of eligibility if not already certified; CCDS certification is required within three years from the date of 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 according to degree; FMG MD-prepared license is not necessary.

• At least 5 years of experience in short-term acute medical/surgical hospital nursing.

• A minimum of 2 years of clinical documentation improvement (CDI) experience.

• Familiarity with payment methodologies and CMS/AHRQ quality metrics.

• Proficient in using Epic EMR and Nuance CDE One.

• For Skilled Nursing Facility: understanding of Medicare Part A guidelines, SNF PPS Final Rule, CMS Clinical Category Crosswalk, MDS RAI Manual, and CMS PDPM Calculator Tool.

• Ability to perform sedentary work, including occasional exertion of up to 10 pounds of force.

🏝️ Benefits

• Comprehensive health insurance plans.

• Retirement savings options with employer matching.

• Opportunities for continuing education and professional development.

• Flexible work schedules and remote work options.

• Supportive work environment promoting work-life balance.