RN Clinical Document Improvement Specialist

Clinical Documentation Improvement (CDI) Specialist-RN

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.

Primary Department, Division, or Unit: Clinical Documentation Improvement, UHS Revenue Cycle Operations

Work Shift and Schedule: This is a per diem position, which means you will work on an as needed, agreed upon basis. Working hours will be assigned by your manager.

Compensation Range: $37.00 - $55.50 per hour, depending on experience. This position is not eligible for benefits.

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