Lead Clinical Documentation Specialist - Utilization Management

Thompson Health; City of Canandaigua (NY); Remote; USD 55,000 - 66,000; Full time

Job summary

UR Medicine Thompson Health in Canandaigua, NY, seeks a Lead Clinical Documentation Specialist (RN) to enhance documentation quality and reimbursement. Remote role with occasional onsite orientation and meetings, with strong leadership and coding expertise expected.

The ideal candidate has a minimum 5 years inpatient RN experience and will oversee CDI practices, coordinate education, and drive program improvements while ensuring HIPAA compliance.

Qualifications

• Licensed RN with minimum of 5 years inpatient clinical experience.
• CDS or CDIP certification required within two years of starting the role.
• Expertise in clinical documentation concepts and compliant documentation practices.

Responsibilities

• Performs extensive medical record review through CDI software integrated with the EMR.
• Leads CDI team and coordinates clinical documentation improvement practices.
• Oversee training and education for providers, nurses and CDI staff.
• Actively participate in team meetings to develop improvement efforts and education regarding the Clinical Documentation Management Program (CDMP)

Skills

CDI Leadership

Clinical Documentation

HIPAA Compliance

Physician Queries

Data Analysis

Education & Training

Team Leadership

EHR Proficiency

Education

AAS

BSN preferred

Tools

Microsoft Office

Job description

Job Category: C - Registered Nurse 030

Requisition Number: LEADC011646

• Posted : October 8, 2026
• Full-Time
• Hybrid

Locations

Showing 1 location

Canandaigua, NY, USA

Description

Are you looking to make a real difference in the lives of others in an empowering and supportive work environment? Join our growing and well-respected community health system and enjoy competitive pay, high patient and staff satisfaction levels, free parking, tuition assistance and other excellent benefits! Join Thompson in this new role of lead clinical documentation specialist!

This position is remote with potential for occasional onsite meeting requirements. Hospital orientation is also required in person.

Main Function

• Performs extensive medical record review through the use of CDI software integrated with the EMR.
• Facilitates clinical documentation improvement through concurrent and retrospective interaction with physicians and members of the healthcare team. This interaction supports the clinical severity of the inpatient admission, quality documentation standards that align with federal and state regulations and assists with maximizing revenue and risk stratification.
• Act as the lead for the CDI team and assist with coordination of clinical documentation improvement practices consistent with corporate compliance guidelines and appropriate financial reimbursement based on the acuity of the patient population.
• Oversee training and education for providers, nurses and other CDI staff.
• Actively participate in team and committee meetings to assist with the development of improvement efforts and education regarding the Clinical Documentation Management Program (CDMP)

Required Job Specific Competencies

• Advanced Clinical Knowledge: including comprehensive understanding of anatomy, physiology, and disease processes
• Expertise in coding and reimbursement methodologies
• Clinical documentation principles: a strong grasp of compliant clinical documentation practices
• Effective physician querying: ability to formulate clear, concise and non-leading queries to physicians and other providers
• Auditing and Quality Assurance: proficiency in conducting retrospective and concurrent review of medical records
• Data Analysis and Reporting: ability to analyze CDI program date, identify trends in documentation and measure program effectiveness
• Education and training development: skill in developing and delivering targeted education and training programs for physicians, advanced practice providers, residents, and other healthcare staff on documentation best practices
• Leadership and mentorship: ability to lead a team of CDI specialists, provide guidance, mentorship and constructive feedback. Foster a collaborative and high-performing work environment
• Technology proficiency: competence in utilizing electronic health record systems, CDI software and other relevant healthcare information technology
• Adherence to all relevant health care regulations and hospital policies related to patient privacy (HIPAA), documentation, and billing

Qualifications

• Licensed RN with minimum of 5 years inpatient clinical experience and extensive knowledge of complex disease processes.
• CDS (Clinical Documentation Specialist) or CDIP (Clinical Documentation Improvement Practitioner certification required within two years of starting the role.

Experience

• Minimum 3-5 years CDI experience
• Leadership experience preferred
• Advanced clinical experience with extensive knowledge of complex disease processes preferred
• Proficiency with computers, spreadsheets and Microsoft office

Education

• AAS required
• BSN preferred or willingness to complete within 5 years of hire

Position Pay Range: $40.00-48.00/hour

Starting Pay: Based on experience

UR Medicine Thompson Health is an EOE encouraging individuals with disabilities and veterans to apply.

Leader

Inspires teammates to follow them

Detail Oriented

Capable of carrying out a given task with all details necessary to get the task done well

Education

Preferred

Associate /Applied Scienc or better in Nursing.

Bachelor of Science or better in Nursing.

Licenses & Certifications

Required

Registered Nurse

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities
This employer is required to notify all applicants of their rights pursuant to federal employment laws.For further information, please review the Know Your Rights notice from the Department of Labor.