Senior Clinical Documentation Specialist - Level II

NYC Health + Hospitals; New York (NY); On-site; USD 85,000 - 105,000; Full time

Job summary

Lincoln Medical and Mental Health Center, part of NYC Health + Hospitals, seeks a Clinical Documentation Specialist to optimize clinical record documentation for appropriate severity of illness and reimbursement. You will coordinate with physicians, coding staff, and leadership to improve documentation accuracy and DRG assignment.

Required qualifications include NYS licensure (RN/NP/PA) and experience in clinical documentation review, with emphasis on ICD-10 guidelines and regulatory compliance.

Qualifications

• Valid New York State license and current registration—RN, NP, or PA.
• Two years of experience in clinical documentation review or utilization/case management.
• Experience with ICD-10 coding and DRG assignment is preferred.

Responsibilities

• Lead clinical documentation improvement initiatives and mentor staff.
• Query physicians to clarify documentation for accurate coding and reimbursement.
• Prepare and present monitoring reports to hospital leadership.

Skills

Clinical documentation

Communication

Leadership

Education

RN licensure

NP licensure

PA licensure

Tools

CCDS Certification

Job description

Lincoln Medical and Mental Health Center, part of NYC Health + Hospitals, seeks a Clinical Documentation Specialist to optimize clinical record documentation for appropriate severity of illness and reimbursement. You will coordinate with physicians, coding staff, and leadership to improve documentation accuracy and DRG assignment.

Required qualifications include NYS licensure (RN/NP/PA) and experience in clinical documentation review, with emphasis on ICD-10 guidelines and regulatory compliance.