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About the Role
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.
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
- Working closely with providers, coders, and quality teams to clarify documentation
- Supporting accurate data capture for clinical, financial, and regulatory reporting
- Applying clinical knowledge and critical thinking skills to identify documentation gaps
- Facilitating timely, compliant provider clarification
Requirements
- Associate’s Degree in Nursing (ASN) or Nursing Diploma
- Working knowledge of encoding system and Excel
- Previous Coding experience
- Valid NYS RN licensure or eligible
Skills
- Clinical knowledge
- Critical thinking skills
Location
- New York’s Southern Tier
Work Type
- Day shift
- Full-time
Experience Level
- Depending on experience
Education Level
- Associate’s Degree in Nursing (ASN) or Nursing Diploma
- Bachelor’s Degree in Nursing (BSN) - Preferred
Salary/Compensations
- $37.00 - $55.50 per hour
Benefits
- Medical coverage
- Dental coverage
- Vision coverage
- 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.
- At UHS, our work is guided by our Values of Compassion, Trust, Respect, Teamwork, and Innovation.
- Every employee plays a meaningful role in fulfilling our mission—we’d love for you to consider joining us!
Equal Opportunity
- United Health Services is an Equal Opportunity Employer.