Clinical Documentation Specialist

RRHS; United States; Remote; USD 85,000 - 120,000; Full time

Job summary

RRHS is seeking a Clinical Documentation Specialist to support Unity Hospital remotely. The role focuses on accurate documentation for SOI, ROM, complexity of care, and quality, via extensive record review and teamwork with physicians and care staff.

Candidates should have an RN (or equivalent) with 5+ years acute care experience, and CCDS/CDIP certification within the eligibility window. Knowledge of CMS metrics and Epic is preferred.

Qualifications

• Registered nursing degree required; other clinical education may be considered.
• 5 years of adult acute care experience in med/surg, critical care, ER, or PACU (as of 03/02/2026).
• CCDS or CDIP certification exam within 6 months of eligibility if not certified.
• 2-3 years' experience with SNF payment methodologies and PDPM (SNF role).
• BSN or RN with BS in applicable field.

Responsibilities

• Reviews medical record for completeness and accuracy for SOI, ROM, complexity of care, and quality.
• Accurate and timely record review.
• Recognize opportunities for documentation improvement.
• Formulate clinically credible documentation clarifications.
• Request documentation clarifications for SOI, ROM, Complexity of Care, Core Measures, and Patient Safety.
• Communicate effectively with physicians.
• Provide education to care team regarding the CDS process.
• Timely follow up on all cases and resolution of clarifications.
• Participate in Team Meetings.
• Manage multiple priorities.
• Communicate with HIM staff to resolve discrepancies.
• Input data accurately into department software.

Education

RN degree

BSN or RN with BS

Epic EMR knowledge

Tools

Epic EMR

Nuance CDE One

Job description

Job Title: Clinical Documentation Specialist

Department: Clinical Documentation Improvement

Location: Unity Hospital (Remote)

Hours Per Week: 40 hours per week

Schedule: Monday- Friday 8 hr. shifts.

SUMMARY:

The role facilitates accurate documentation for severity of illness, expected risk of mortality, complexity of care and quality in the medical record. This involves extensive record review and interaction with members of the healthcare team and ancillary teams.

RESPONSIBILITIES:

• Reviews medical record for completeness and accuracy for severity of illness (SOI), risk of mortality (ROM), complexity of care, and quality.
• Accurate and timely record review.
• Recognize opportunities for documentation improvement.
• Formulate clinically credible documentation clarifications.
• Request documentation clarifications as appropriate for SOI, ROM, Complexity of Care, Core Measures, and Patient Safety.
• Effective and appropriate communication with physicians.
• Provides education to members of the patient care team regarding the CDS process.
• Timely follow up on all cases and resolution of those with clinical documentation clarifications.
• Actively participate in Team Meetings.
• Manage multiple priorities.
• Communicates with HIM staff and resolves discrepancies.
• Accurate input of data into department software.

For Skilled Nursing Facility Only:

• Utilize the ICD-10-CM Official Guidelines for Coding & Reporting and their application in the long-term healthcare setting.
• Utilize an ICD-10-CM indexing system to determine appropriate ICD-10-CM codes.
• Collaborate with the hospital and skilled nursing facility (SNF) team members to ensure documentation supports the most specified, appropriate, and billable ICD-10-CM code(s) for primary and secondary diagnoses (co-morbidities) to be assigned for a SNF authorization, and PPS assessments required under PDPM.

MINIMUM QUALIFICATIONS:

• Registered nursing degree required, other clinical education may be considered, such as PA, NP, MD or Foreign Medical Graduate (FMG) MD prepared.
• Effective as of 03/02/2026, will consider active unrestricted RN candidates (or other clinicians as defined below) with at least 5 years of adult acute care experience in med/surg, critical care, emergency room, or PACU.
• If no certification, must complete CCDS or CDIP certification exam after completing two years full time equivalent of CDS hours. Must pass certification exam within 6 months of eligibility.
• For Skilled Nursing Facility Only: Registered nursing degree required, other clinical education may be considered, such as PA, NP, or MD or Foreign Medical Graduate (FMG) MD prepared.
• Effective as of 03/02/2026, will consider active unrestricted RN candidates (or other clinicians as defined below) with at least 5 years of adult acute care experience in med/surg, critical care, emergency room, or PACU.
• Effective as of 03/02/2026, 2-3 years' experience with SNF payment methodologies and PDPM.

PREFERRED QUALIFICATIONS:

• CCDS certification preferred at hire.
• Previous CDS experience preferred.
• Minimum 5 years short term acute medical/surgical hospital nursing experience.
• BSN or RN with BS in applicable field.
• Minimum of two years CDI experience.
• Preferred CCDS or CDIP certification.
• Knowledge of payment methodologies and CMS/AHRQ Quality metrics.
• Working knowledge of Epic EMR and Nuance CDE One.
• 5+ years of adult acute care experience in Med/surg, critical care, emergency room, or PACU
• For Skilled Nursing Facility Only: Understand Medicare Part A guidelines.
• For Skilled Nursing Facility Only: Understand the current FY SNF PPS Final Rule.
• For Skilled Nursing Facility Only: Understand the CMS Clinical Category Crosswalk tool for PDPM ICD-10-CM Mappings.
• For Skilled Nursing Facility Only: Understand the MDS Resident Assessment Instrument (RAI) Manual.
• For Skilled Nursing Facility Only: Ability to use the CMS PDPM Calculator Tool.

Required Licensure/Certification:

• Current professional licensure in the state of New York based on degree. Foreign Medical Graduate (FMG) MD Prepared License not required.
• Effective as of 03/02/2026, Effective 3 years from hire, CCDS certification required.
• For Skilled Nursing Facility Only: Current professional licensure in the state of New York based on degree. Foreign Medical Graduate (FMG) MD Prepared License is not required.
• CCDS certification is not required.

PHYSICAL REQUIREMENTS:

Sedentary - Sedentary roles are primarily office-based and require prolonged sitting (67-100% of the workday) with minimal physical effort and lifting limited to under 10 lbs. Fine motor skills are necessary for computer work, writing, and telephone use, supported by clear visual and auditory ability. Cognitive and emotional demands are high due to extended concentration, frequent interruptions, independent decision-making, and information processing. Although physical exposure is low, administrative areas within healthcare environments may occasionally involve contact with infectious agents. Some roles may require flexible hours, TB screening, or a valid driver's license.

For disease specific care progr