Clinical Documentation Specialist I — Remote Impact

NYC Health + Hospitals; New York (NY); On-site; USD 95,000 - 140,000; Full time

Job summary

NYC Health + Hospitals in New York is seeking a Clinical Documentation Specialist to support accurate severity of illness and proper reimbursement through physician documentation reviews, queries, and validation. The role requires collaboration with physicians, coding staff, and leadership to improve DRG accuracy and patient outcomes.

The specialist will perform concurrent and retrospective record reviews, education on documentation and coding, and contribute to QA/PI activities while ensuring

Qualifications

• RN/NP/PA license options with NYS registration.
• Experience reviewing clinical documentation for severity of illness.
• Familiarity with medical coding guidelines and DRG assignment.

Responsibilities

• Facilitate and obtain physician documentation to support severity of illness and proper reimbursement.
• Perform concurrent and retrospective reviews of patient records for DRG assignment and CMI.
• Query physicians to clarify incomplete or conflicting documentation to ensure accuracy.
• Provide feedback and follow-up reviews to ensure updated documentation.
• Educate providers on documentation and coding guidelines and engage in QA/PI activities.
• Contribute to trending and reporting for leadership review.

Skills

CDIS Guidelines

AHIMA Coding

Querying physicians

Education

Registered Nurse license

Nurse Practitioner license

Physician Assistant license

Foreign Medical Graduate

Tools

EPIC

3M 360

Job description

NYC Health + Hospitals in New York is seeking a Clinical Documentation Specialist to support accurate severity of illness and proper reimbursement through physician documentation reviews, queries, and validation. The role requires collaboration with physicians, coding staff, and leadership to improve DRG accuracy and patient outcomes.

The specialist will perform concurrent and retrospective record reviews, education on documentation and coding, and contribute to QA/PI activities while ensuring