Remote CDI & Clinical Documentation Specialist

Rochester Regional Health; City of Rochester (NY); À distance; USD 78 000 - 96 000; Plein temps

Résumé du poste

Rochester Regional Health is seeking a Clinical Documentation Specialist to ensure accurate documentation of severity of illness, ROM, and care complexity. You will review records, educate teams, and collaborate with physicians to clarify documentation and improve coding accuracy.

Remote options within Unity Hospital's CDS program may be available; active NY RN licensure and CDS certification within 6 months are required or preferred.

Qualifications

• RN degree required with active NY licensure.
• 5+ years of adult acute care experience in med/surg, critical care, ER, or PACU.
• CCDS or CDIP certification preferred; if not certified, must obtain within 6 months.
• Knowledge of ICD-10-CM, PDPM, CMS quality metrics is desirable.

Responsabilités

• Review medical records for SOI, ROM, and quality to ensure accuracy.
• Identify opportunities for documentation improvement and request clarifications.
• Educate care teams on the CDS process and collaborate with physicians.
• Input data accurately into department software and participate in team meetings.
• Manage multiple priorities and resolve discrepancies with HIM staff.
• For SNF: apply ICD-10-CM guidelines and coordinate PDPM related coding.

Connaissances

RN

Clinical experience

CDS knowledge

Formation

Registered Nurse degree

Outils

Epic EMR

Nuance CDE One

CMS PDPM Calculator Tool

Description du poste

Rochester Regional Health is seeking a Clinical Documentation Specialist to ensure accurate documentation of severity of illness, ROM, and care complexity. You will review records, educate teams, and collaborate with physicians to clarify documentation and improve coding accuracy.

Remote options within Unity Hospital's CDS program may be available; active NY RN licensure and CDS certification within 6 months are required or preferred.