Registered Nurse (RN) - Clinical Document Improvement Specialist - $37-56 per hour (Hiring Immediately)

United Health Services is seeking a Registered Nurse (RN) Clinical Document Improvement Specialist for a nursing job in Johnson City, New York. Job Description & Requirements Specialty: Clinical Document Improvement Specialist Discipline: RN Duration: Ongoing 40 hours per week Shift: 8 hours Employment Type: Staff The Clinical Documentation Improvement (CDI) Specialist-RN is a registered nurse responsible for performing concurrent and retrospective reviews of inpatient medical records to ensure complete, accurate, and compliant clinical documentation. This role focuses on supporting accurate ICD 10 CM/PCS coding, MS DRG assignment, severity of illness (SOI), risk of mortality (ROM), quality reporting, and reimbursement integrity. This role works closely with providers, coders, and quality teams to clarify documentation and support accurate data capture for clinical, financial, and regulatory reporting. This role applies clinical knowledge and critical thinking skills to identify documentation gaps and facilitate timely, compliant provider clarification. Education/Experience Minimum Required: Associate’s Degree in Nursing (ASN) or Nursing Diploma. Preferred: Bachelor’s Degree in Nursing (BSN). Working knowledge of encoding system and Excel. Previous Coding experience. License/Certification Minimum Required: Valid NYS RN licensure or eligible. Preferred: CCS (Certified Coding Specialist) – AHIMA CIC (Certified Inpatient Coder)-AAPC CCDS (Certified Clinical Documentation Specialist)–ACDIS Work Environment May be remote, hybrid, or onsite depending on facility needs. Requires prolonged periods of computer use and attention to detail. The office is air conditioned as well as heated. Age of Patients Served Not Applicable HIPAA Roles-Based Access to Patient Information All – Access to patient information, including restricted information – Level 4 United Health Services Job ID R0000014760. Posted job title: RN Clinical Documentation Improvement Specialist About United Health Services United Health Services (UHS) is more than a healthcare system. We are a compassionate, people-focused organization dedicated to improving the health of the communities that we serve. As a locally owned, not-for-profit network, our team of more than 7,000 caregivers and professionals is united by the shared purpose to deliver safe, patient-centered care. At UHS, every role matters. However you contribute, you will be part of a supportive, connected culture that values your voice and encourages growth. We are committed to helping you thrive through meaningful benefits, development opportunities, and a strong sense of belonging. Here, you are not just building a career—you are making a difference every day in the lives of others. Benefits Holiday Pay Continuing Education 403b retirement plan Pet insurance Sick pay Wellness and fitness programs Mileage reimbursement Employee assistance programs Medical benefits Dental benefits Vision benefits Benefits start day 1 License and certification reimbursement Life insurance5c143e31-5e48-4549-b638-05792d185386