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About the Role

The Clinical Documentation Improvement (CDI) Specialist – CDI-coder performs reviews of medical records to ensure complete, accurate, and compliant clinical documentation. This role supports accurate ICD 10 CM/PCS coding, MS DRG assignment, severity of illness (SOI), risk of mortality (ROM), quality reporting, and reimbursement integrity by clarifying documentation with providers, coders, and quality teams.

Responsibilities

Performing concurrent and retrospective reviews of inpatient medical records
Ensuring complete, accurate, and compliant clinical documentation
Supporting accurate ICD 10 CM/PCS coding, MS DRG assignment, severity of illness (SOI), risk of mortality (ROM), quality reporting, and reimbursement integrity
Clarifying documentation with providers, coders, and quality teams to support accurate data capture for clinical, financial, and regulatory reporting

Requirements

RHIT certification with an Associate degree in HIT
2–5 years of inpatient hospital coding experience
RHIA certification with a Bachelor’s Degree in HIT (Preferred)
CCS (Certified Coding Specialist) – AHIMA-preferred
CIC (Certified Inpatient Coder)-AAPC-preferred
CCDS (Certified Clinical Documentation Specialist)–ACDIS- preferred

Work Type

Day shift
40 hours per week

Experience Level

2-5 years inpatient hospital coding experience

Education Level

Associate degree in HIT
Bachelor's Degree in HIT (Preferred)

Salary/Compensations

$30.58 - $45.86 per hour

Benefits

Medical, dental, and vision coverage starting the first of the month after hire for employees working 24+ hours/week
Flexible plan options and coverage tiers
Discounted childcare through Bright Horizons
Voluntary benefits like pet insurance, legal services, and identity theft protection
PTO starts accruing from day one
403(b) retirement plan with company match
Flexible spending accounts
Access to financial advisors
Up to $400/year in wellness rewards
24/7 EAP counseling
Virtual mental health support
Food pantry
PTO donation program
Professional attire through the Classy Closet
Access to 100,000+ online courses
Leadership programs
Tuition reimbursement
Clinical ladders
Internal mobility

About the Company

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.
UHS's work is guided by its Values of Compassion, Trust, Respect, Teamwork, and Innovation.
UHS offers more than a career—it offers a lifestyle in New York’s Southern Tier, with four-season recreation, affordable living, top-rated schools, minor league sports, craft brews, a close-knit community, and proximity to the Finger Lakes, the Catskills, and major Northeast cities.

Equal Opportunity

United Health Services is an Equal Opportunity Employer.
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.