CDI Specialist I — Elevate Documentation & Reimbursement

NYC Health + Hospitals; New York (NY); On-site; USD 85,000 - 120,000; Full time

Job summary

Harlem Hospital Center, part of NYC Health + Hospitals, seeks a Clinical Documentation professional to optimize documentation and reimbursement. The role emphasizes collaboration with physicians and coding staff to ensure accurate severity of illness, DRG and case mix, while maintaining patient‑centered care.

Responsibilities include reviewing records, querying providers for clarification, and educating staff on documentation and coding guidelines. Remote/on-site flexibility may apply as needed.

Qualifications

• Valid NYS license and current registration as an RN with BSN and four years acute care experience.
• NYS license and current registration to practice as a Nurse Practitioner (NP) with two years’ experience.

Responsibilities

• Facilitates improvement in documentation quality and accuracy through chart review and clinician queries.
• Obtains physician documentation to capture acuity, severity of illness, and mortality risk.
• Reviews records to assign DRG and Case Mix Index (CMI).
• Queries clinicians to clarify documentation and ensures final coding accuracy.
• Educates providers on documentation and coding guidelines and reimbursement impacts.
• Participates in meetings and QA/PI activities.

Skills

Medical records review

Clinical documentation

Communication skills

Education

RN with BSN (NY)

Nurse Practitioner (NY)

Physician Assistant (NY)

Foreign Medical Graduate

Job description

Harlem Hospital Center, part of NYC Health + Hospitals, seeks a Clinical Documentation professional to optimize documentation and reimbursement. The role emphasizes collaboration with physicians and coding staff to ensure accurate severity of illness, DRG and case mix, while maintaining patient‑centered care.

Responsibilities include reviewing records, querying providers for clarification, and educating staff on documentation and coding guidelines. Remote/on-site flexibility may apply as needed.