Clinical Documentation Specialist, Level 1

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 has been a bedrock of the Harlem community since 1887. The hospital provides a wide range of medical, surgical, diagnostic, therapeutic and family support services to the residents of Central Harlem, West Harlem, Washington Heights and Inwood. Harlem is the largest hospital in the area, capable of treating the most seriously ill. Harlem provides over 90 specialized ambulatory care services, dentistry and oral surgery, behavioral health services, and community substance abuse treatment.

Harlem Hospital Center has been a bedrock of the Harlem community since 1887. The hospital provides a wide range of medical, surgical, diagnostic, therapeutic and family support services to the residents of Central Harlem, West Harlem, Washington Heights and Inwood. Harlem is the largest hospital in the area, capable of treating the most seriously ill. Harlem provides over 90 specialized ambulatory care services, dentistry and oral surgery, behavioral health services, and community substance abuse treatment.

At NYC Health + Hospitals, our mission is to deliver high quality care health services, without exception. Every employee takes a person-centered approach that exemplifies the ICARE values (Integrity, Compassion, Accountability, Respect, and Excellence) through empathic communication and partnerships between all persons.

Duties & Responsibilities

Purpose of Position

Under the direction of the Director of Clinical Documentation, Director of Health Information Management or a designee for revenue management and recovery, facilitates and obtains appropriate physician documentation for clinical conditions or procedures to support the appropriate severity of Illness, expected risk of mortality, and complexity of patient care and to optimize reimbursement, ensuring patient centered quality care, optimal utilization of resources, service delivery and compliance with NYC Health + Hospitals, hospital, and all relevant regulatory policies, procedures, and standards of care for better outcomes and improved patient experience. Demonstrates effective communication, planning, and organizational skills and keeps current knowledge in the clinical documentation field and of all applicable regulations. All personnel perform related work and may perform tasks remotely, as authorized.

Under supervision, performs assigned duties related to reviewing, reporting, processing and quality assurance of clinical documentation.

Examples Of Typical Tasks

• Facilitates improvement in the overall quality, completeness, accuracy, specificity and timeliness of physician clinical record documentation through extensive medical record review, query process, and effective communication with appropriate clinical and coding staff, and by utilizing computer programs and systems.
• Obtains appropriate physician documentation for clinical conditions or procedures through extensive on-going interaction with physicians, other patient caregivers, and medical records coding staff to ensure the clinical documentation properly captures information describing patients’ acuity, severity of illness, and risk of mortality. Reflects the level of service delivered to patients is appropriate, complete, and accurate and supports appropriate reimbursement for the level of service rendered to all patients.
• Completes concurrent and retrospective reviews of patient records for a specified patient population to evaluate documentation to assign the principal diagnosis, pertinent secondary diagnoses, postadmission complications and procedures for accurate Diagnosis-Related Group (DRG) assignment and Case Mix Index (CMI), risk of mortality, and severity of illness.
• Queries physicians for incomplete, inconsistent, unclear or conflicting health record documentation to clarify and resolve conflicting information in patient’s medical record prior to patient’s discharge; maintains a record of review and query activities and other appropriate records.
• Provides feedback and completes follow-up review of patient medical record, to ensure points of clarification have been addressed and recorded in the patient’s chart, and to assign a working/updated or final DRG upon patient discharge and before final coding and quality reporting submissions, as necessary.
• Identifies and reports areas of weakness that may impact financial opportunities, and works with Finance or other appropriate staff in resolution of problems.
• Participates in the analysis and trending of statistical data for specified patient populations to identify opportunities for improvement.
• Assists with preparation and presentation of clinical documentation monitoring/trending reports for review with physicians and hospital leadership.
• Assists in the orientation and training of new staff members, and provides continual guidance and mentoring, as required.
• Educates providers on proper clinical documentation and coding guidelines and practices, and compliance and reimbursement issues on an ongoing basis. Advises on the impact of provider documentation on accurate reporting of a patient’s clinical information and reimbursement.
• Attends and/or participates in staff, departmental and interdisciplinary meetings, LEAN efficiency/ process improvement events, training and quality assurance/performance improvement (QA/PI) activities.
• Performs other related work, as assigned.

Minimum Qualifications

• Valid New York State license and current registration to practice as a Registered Professional Nurse(RN) issued by the New York State Education Department (NYSED); and Bachelor of Science inNursing degree from an accredited college or university; and four (4) years of acute care experience;or
• Valid New York State license and current registration to practice as a Nurse Practitioner (NP) issuedby the NYSED; and two (2) years of experience, as described in “1” above; or
• Valid New York State license and current registration to practice as a Physician Assistant (PA)issued by the NYSED; and two (2) years of experience, as described in “1” above; or
• Foreign Medical Graduate; and, two (2) years of medical records review or utilization and case management experience; or
• Successful completion of education that leads to a medical degree; and two (2) years of experience,as described in “4” above.