RN Clinical Documentation Improvement Specialist

02 UHS Hospitals; City of Binghamton (NY); On-site; USD 51,000 - 77,000; Full time

Job summary

United Health Services (UHS) in New York's Southern Tier seeks a CDI Specialist-RN to perform concurrent and retrospective reviews of inpatient records, ensuring complete, accurate, and compliant documentation.

You will support ICD-10-CM/PCS coding, MS-DRG assignment, SOI/ROM, quality reporting, and reimbursement integrity while collaborating with providers, coders, and quality teams. This role demands clinical knowledge, critical thinking, and timely provider clarification.

Qualifications

• ASN or Nursing Diploma required; BSN preferred.
• Working knowledge of encoding systems and Excel.
• Previous coding experience preferred.

Responsibilities

• Perform concurrent and retrospective reviews of inpatient medical records.
• Ensure complete, accurate, and compliant clinical documentation.
• Support ICD-10-CM/PCS coding, MS-DRG assignment, SOI/ROM, and quality reporting.

Skills

Critical thinking

Clinical documentation

Provider communication

Data accuracy

Education

ASN or Nursing Diploma

BSN preferred

Tools

Excel

Coding/Encoding systems

Job description

Position Overview

The Clinical Documentation Improvement (CDI) Specialist-RN is a registered nurse responsible for performing concurrent and retrospective reviews of inpatient medical records to ensure complete, accurate, and compliant clinical documentation. This role focuses on supporting accurate ICD 10 CM/PCS coding, MS DRG assignment, severity of illness (SOI), risk of mortality (ROM), quality reporting, and reimbursement integrity. This role works closely with providers, coders, and quality teams to clarify documentation and support accurate data capture for clinical, financial, and regulatory reporting. This role applies clinical knowledge and critical thinking skills to identify documentation gaps and facilitate timely, compliant provider clarification.

Primary Department, Division, or Unit: Facility Coding, UHS Revenue Cycle Operations

Primary Work Shift: Day Regular Scheduled

Weekly Hours: 40

Compensation Range: $37.00 - $55.50 per hour, depending on experience

Education/Experience

• Minimum Required: Associate’s Degree in Nursing (ASN) or Nursing Diploma.
• Preferred: Bachelor’s Degree in Nursing (BSN).
• Working knowledge of encoding system and Excel.
• Previous Coding experience.

License/Certification

• Minimum Required: Valid NYS RN licensure or eligible.
• Preferred: CCS (Certified Coding Specialist) – AHIMA CIC (Certified Inpatient Coder)-AAPC CCDS (Certified Clinical Documentation Specialist)–ACDIS

Why You’ll Love Working at UHS

At United Health Services (UHS), we believe every connection to patients, to purpose, to each other makes a difference. That’s why we’re intentional about supporting our team in ways that go beyond the job. Whether through meaningful benefits, personal growth, or fun along the way, we’re here to help you thrive in work and life.

A Culture of Connection - We support each other like family and create space for every voice to be heard. Engagement Councils, peer recognition, and initiatives like Walk in my Shoes for senior leaders are just a few ways we foster belonging and collaboration. Outside of work, we stay connected through team events like trivia, trunk-or-treat, volunteer days, our staff choir, or seasonal celebrations.

Comprehensive Benefits for Life & Family

• We offer medical, dental, and vision coverage starting the first of the month after hire for employees working 24+ hours/week.
• With flexible plan options and coverage tiers, you can choose what fits your life best.
• Additional perks include discounted childcare through Bright Horizons and voluntary benefits like pet insurance, legal services, and identity theft protection.

Well-Being & Financial Security

• From day one, PTO starts accruing so you can take time to recharge.
• We support your long-term wellness with a 403(b) retirement plan and company match, flexible spending accounts, access to financial advisors, and up to $400/year in wellness rewards.
• When life gets tough, we’re here with 24/7 EAP counseling, virtual mental health support, a food pantry, PTO donation program, and professional attire through the Classy Closet.

Growth That Moves with You

With access to 100,000+ online courses, leadership programs, tuition reimbursement, clinical ladders, and internal mobility, we help you grow wherever your passion leads. We also continuously review compensation to ensure market competitiveness and internal equity, so you can feel confident your work is valued and rewarded fairly.

A Place to Call Home

Located in New York’s Southern Tier, UHS offers more than a career—we offer a lifestyle. Enjoy four-season recreation, affordable living, top-rated schools, minor league sports, craft brews, a close-knit community, and more, all within reach of the Finger Lakes, the Catskills, and major Northeast cities.

About United Health Services

United Health Services (UHS) is a locally owned, not-for-profit healthcare system in New York’s Southern Tier comprising four hospitals, long-term care and home care services, and physician practices in Broome and surrounding counties. UHS provides healthcare and medical services for two-thirds of the region’s population, produces $1.3 billion a year in total economic impact, and boasts a workforce of more than 6,300 employees and providers. At UHS, our work is guided by our Values of Compassion, Trust, Respect, Teamwork, and Innovation. Whether you provide direct patient care or support behind the scenes, you are part of a shared purpose: to improve the health and well-being of the communities we serve. Every employee plays a meaningful role in fulfilling our mission—we’d love for you to consider joining us!

United Health Services is an Equal Opportunity Employer.

Disclaimer

United Health Services, Inc. and the members of the UHS System neither are affiliated with, sponsored, endorsed nor approved by, nor otherwise associated with, Universal Health Services, Inc. (NYSE: UHS), UHS of Delaware, Inc. nor their affiliates, which can be found at www.uhsinc.com.

Make New Connections

We believe that people—and the connections among them—must remain at the core of everything we do. Whether you're directly caring for patients, supporting our clinical operations, or working to ensure our administrative functions run effectively, your impact will be recognized and appreciated.

Unlock Greater Opportunities

Our commitment to you extends beyond a paycheck. We want you to thrive professionally and personally. Not only will you provide care and support for our patients, but you'll also be cared for, too. While many organizations make this claim, we back it up with action. We take workforce feedback seriously and we continually implement new education initiatives, compensation models, and recognition programs in service of our people.

Proud to be Team UHS

Our footprint spans across every part of New York's Southern Tier. But we don't just serve our community, we're a part of it, too. We are volunteers, coaches, local leaders, parents or grandparents, and mentors. UHS team members can be found at almost every local walk, fundraiser, and sporting event. We promote wellness and health equity within and far beyond our walls.

Benefits for Full-time and Part-time Employees

UHS proudly offers benefits to all full-time employees and part-time employees who are hired into a regular position of at least 24 hours per week (60% FTE).