Inpatient Coder - Clinical Documentation Improvement (CDI) Specialist

Position Overview

United Health Services (UHS) is seeking a Clinical Documentation Improvement (CDI) Specialist – CDI Coder to support accurate, complete, and compliant clinical documentation across the inpatient setting. The Clinical Documentation Improvement (CDI) Specialist – CDI Coder collaborates with physicians, coders, and interdisciplinary care teams to ensure medical records accurately reflect patient acuity, severity of illness, risk of mortality, and services provided. Through concurrent and retrospective chart reviews, this role helps optimize coding accuracy, reimbursement integrity, quality reporting, and regulatory compliance.

The Clinical Documentation Improvement (CDI) Specialist – CDI Coder serves as a key resource for documentation excellence by identifying opportunities for clarification, educating providers on documentation best practices, and facilitating compliant clinical queries. This position plays a critical role in supporting accurate ICD-10-CM/PCS coding, MS-DRG assignment, and organizational quality initiatives while promoting data integrity and improved patient care outcomes.

Primary Department, Division, or Unit

Clinical Documentation Improvement, UHS Revenue Cycle Operations

Primary Work Shift

Day

Regular Scheduled Weekly Hours

40

Compensation Range

$30.58 - $45.86 per hour, depending on experience

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Job Responsibilities

• Review inpatient clinical documentation to improve the accuracy, completeness, and quality of the medical record.
• Conduct initial and follow-up documentation reviews to ensure diagnoses, procedures, and clinical indicators are appropriately documented.
• Collaborate with physicians and other healthcare providers to clarify documentation and support accurate clinical representation of patient care.
• Develop and issue compliant, clinically supported provider queries in accordance with AHIMA, ACDIS, and organizational guidelines.
• Assign and validate working MS-DRG and APR-DRG classifications through concurrent documentation review and coding analysis.
• Serve as a clinical documentation resource by educating providers and healthcare professionals on documentation best practices and ICD-10 requirements.
• Partner with coding staff to resolve documentation and coding questions and ensure accurate reimbursement and quality reporting.
• Monitor documentation to support appropriate severity of illness, risk of mortality, quality metrics, and reimbursement outcomes.
• Meet established productivity and accuracy standards while maintaining thorough and timely chart reviews.
• Participate in continuous quality improvement initiatives, departmental meetings, and ongoing professional development to maintain required credentials and industry knowledge.

Position Qualifications

Minimum Required

• RHIT certification with an Associate degree in HIT.
• Minimum 2–5 years of inpatient hospital coding experience
• RHIT certification

Preferred

• RHIA certification with a Bachelor’s Degree in HIT.
• RHIA certification
• CCS (Certified Coding Specialist) – AHIMA-preferred
• CIC (Certified Inpatient Coder)-AAPC-preferred
• CCDS (Certified Clinical Documentation Specialist)–ACDIS- preferred

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Why You’ll Love Working at UHS

At United Health Services (UHS), we believe every connection—to patients, to purpose, to each other—makes a difference. That’s why we’re intentional about supporting our team in ways that go beyond the job. Whether through meaningful benefits, personal growth, or fun along the way, we’re here to help you thrive in work and life.

A Culture of Connection – We support each other like family and create space for every voice to be heard. Engagement Councils, peer recognition, and initiatives like Walk in my Shoes for senior leaders are just a few ways we foster belonging and collaboration. Outside of work, we stay connected through team events like trivia, trunk-or-treat, volunteer days, our staff choir, or seasonal celebrations.

Comprehensive Benefits for Life & Family – We offer medical, dental, and vision coverage starting the first of the month after hire for employees working 24+ hours/week. With flexible plan options and coverage tiers, you can choose what fits your life best. Additional perks include discounted childcare through Bright Horizons and voluntary benefits like pet insurance, legal services, and identity theft protection.

Well-Being & Financial Security – From day one, PTO starts accruing so you can take time to recharge. We support your long-term wellness with a 403(b) retirement plan and company match, flexible spending accounts, access to financial advisors, and up to $400/year in wellness rewards. When life gets tough, we’re here with 24/7 EAP counseling, virtual mental health support, a food pantry, PTO donation program, and professional attire through the Classy Closet.

Growth That Moves with You – With access to 100,000+ online courses, leadership programs, tuition reimbursement, clinical ladders, and internal mobility, we help you grow wherever your passion leads. We also continuously review compensation to ensure market competitiveness and internal equity, so you can feel confident your work is valued and rewarded fairly.

A Place to Call Home – Located in New York’s Southern Tier, UHS offers more than a career—we offer a lifestyle. Enjoy four-season recreation, affordable living, top-rated schools, minor league sports, craft brews, a close-knit community, and more, all within reach of the Finger Lakes, the Catskills, and major Northeast cities.

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About United Health Services

United Health Services (UHS) is a locally owned, not-for-profit healthcare system in New York’s Southern Tier comprising four hospitals, long-term care and home care services, and physician practices in Broome and surrounding counties. UHS provides healthcare and medical services for two-thirds of the region’s population, produces $1.3 billion a year in total economic impact, and boasts a workforce of more than 6,300 employees and providers.

At UHS, our work is guided by our Values of Compassion, Trust, Respect, Teamwork, and Innovation. Whether you provide direct patient care or support behind the scenes, you are part of a shared purpose: to improve the health and well-being of the communities we serve. Every employee plays a meaningful role in fulfilling our mission—we’d love for you to consider joining us!

United Health Services is an Equal Opportunity Employer.

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United Health Services, Inc. and the members of the UHS System neither are affiliated with, sponsored, endorsed nor approved by, nor otherwise associated with, Universal Health Services, Inc. (NYSE: UHS), UHS of Delaware, Inc. nor their affiliates, which can be found at