Top 30 Clinical documentation specialist Jobs in Rochester, Ny

Clinical Documentation Specialist
Unity Hospital of Rochester —Rochester, NY
- $78,000 - $96,200 a year
- 8 hour shift
- Remote
- Nursing
- Medicine
- RN License
Quick Apply
6d
Clinical Document Spec
University of Rochester —Rochester, NY
- $81,307 - $109,761 a year
- Full-time
- Remote
- Nursing
- Medicine
- Surgery
RN, Clinical Document Spec
University of Rochester —Rochester, NY
- $81,307 - $109,761 a year
- Full-time
- Remote
- Nursing
- Medicine
- Surgery
Medical Coding Specialist
TRILLIUM HEALTH INC —Rochester, NY
- $23.00 - $33.11 an hour
- Full-time
- HIPAA
- Mid-level
- Mentoring
Quick Apply
5d
Per Diem Clinical Research Nurse - Home Visits
Science 37 —Rochester, NY
- $50 - $55 an hour
- Nights as needed
- Nursing
- RN License
- BLS Certification
Clinical Research Regulatory Specialist II
University of Rochester —Rochester, NY
- $24.91 - $34.87 an hour
- Day shift
- Mid-level
- Office
- University
Coder - Inpatient
Rochester General Hospital —Rochester, NY
- $22 - $32 an hour
- Full-time
- Mid-level
- Associate's degree
- 2 years
Quick Apply
4d
Credentialing Administrator I
University of Rochester —Rochester, NY
- $27.16 - $38.03 an hour
- Online Application
- Remote
- Word processing
- English
- Research
11d
Human Subject Research Specialist II
University of Rochester —Rochester, NY
- $25.14 - $35.24 an hour
- Part-time
- Blood sampling
- Word processing
- Mid-level
1d
Outcomes Specialist I, CHeT
University of Rochester —Rochester, NY
- $23.27 - $32.60 an hour
- Full-time
- Hybrid work
- Microsoft Excel
- University
- Bachelor's degree
Human Subject Research Specialist I
University of Rochester —Rochester, NY
- $21.78 - $30.53 an hour
- Day shift
- Word processing
- University
- Associate's degree
8h
Credentialing Coordinator
University of Rochester —Rochester, NY
- $23.27 - $32.60 an hour
- Full-time
- Remote
- English
- Research
- Mid-level
Sr Human Subject Research Specialist
University of Rochester —Rochester, NY
- $29.33 - $41.06 an hour
- Full-time
- 5 years
- Word processing
- University
8d
Mohs Surgery Nurse (RN/LPN)
Dermatology Associates of Rochester —Rochester, NY
- $28 - $37 an hour
- Full-time
- CPR Certification
- Nursing
- Vital signs
Quick Apply
Sr. Reg Affairs & Compl Spec
University of Rochester —Rochester, NY
- $70,600 - $105,800 a year
- Full-time
- Surgery
- OSHA
- 5 years
Pediatric Registered Nurse (Community-based)
University of Rochester —Rochester, NY
- $35.35 - $47.72 an hour
- Weekends as needed
- Nursing
- RN License
- Urgent Care
Sr Clin Research Reg Supt Spec
University of Rochester —Rochester, NY
- $29.33 - $41.06 an hour
- Full-time
- Surgery
- Bachelor's degree
- Travel
Registered Nurse
Unity Hospital of Rochester —Rochester, NY
- $38.67 - $51.92 an hour
- Part-time
- Nursing
- RN License
- Hospital
- Continuing education credits
Quick Apply
REGISTERED NURSE - FLEX
CATHOLIC CHARITIES FAMILY AND COMMUNITY SERVICES —Rochester, NY
- $35 - $38 an hour
- Full-time
- Spanish
- Nursing
- Patient monitoring
- 403(b)
Quick Apply
Lab Registration and Billing Specialist - RGH (Full-Time, Days)
Rochester General Hospital —Rochester, NY
- $18.75 - $23.00 an hour
- 8 hour shift
- Hospital
- Word processing
- Mid-level
Quick Apply
4h

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Clinical Documentation Specialist

Unity Hospital of Rochester -
Rochester, NY

Quick Apply

Job Details

Full-time
$78,000 - $96,200 a year
6 days ago

Qualifications

RN License
Acute care facility experience

Full Job Description

Job Title: Clinical Documentation Specialist

Department: Clinical Documentation Improvement

Location: Unity Hospital (Remote)

Hours Per Week: 40 hours per week

Schedule: Monday- Friday 8 hr. shifts.

SUMMARY:

The role facilitates accurate documentation for severity of illness, expected risk of mortality, complexity of care and quality in the medical record. This involves extensive record review and interaction with members of the healthcare team and ancillary teams.

RESPONSIBILITIES:

Reviews medical record for completeness and accuracy for severity of illness (SOI), risk of mortality (ROM), complexity of care, and quality.
Accurate and timely record review.
Recognize opportunities for documentation improvement.
Formulate clinically credible documentation clarifications.
Request documentation clarifications as appropriate for SOI, ROM, Complexity of Care, Core Measures, and Patient Safety.
Effective and appropriate communication with physicians.
Provides education to members of the patient care team regarding the CDS process.
Timely follow up on all cases and resolution of those with clinical documentation clarifications.
Actively participate in Team Meetings.
Manage multiple priorities.
Communicates with HIM staff and resolves discrepancies.
Accurate input of data into department software.

For Skilled Nursing Facility Only:

Utilize the ICD-10-CM Official Guidelines for Coding & Reporting and their application in the long-term healthcare setting.
Utilize an ICD-10-CM indexing system to determine appropriate ICD-10-CM codes.
Collaborate with the hospital and skilled nursing facility (SNF) team members to ensure documentation supports the most specified, appropriate, and billable ICD-10-CM code(s) for primary and secondary diagnoses (co-morbidities) to be assigned for a SNF authorization, and PPS assessments required under PDPM.

MINIMUM QUALIFICATIONS:

Registered nursing degree required, other clinical education may be considered, such as PA, NP, MD or Foreign Medical Graduate (FMG) MD prepared.
Effective as of 03/02/2026, will consider active unrestricted RN candidates (or other clinicians as defined below) with at least 5 years of adult acute care experience in med/surg, critical care, emergency room, or PACU.
If no certification, must complete CCDS or CDIP certification exam after completing two years full time equivalent of CDS hours. Must pass certification exam within 6 months of eligibility.

For Skilled Nursing Facility Only:

Registered nursing degree required, other clinical education may be considered, such as PA, NP, or MD or Foreign Medical Graduate (FMG) MD prepared.
Effective as of 03/02/2026, will consider active unrestricted RN candidates (or other clinicians as defined below) with at least 5 years of adult acute care experience in med/surg, critical care, emergency room, or PACU.
Effective as of 03/02/2026, 2-3 years' experience with SNF payment methodologies and PDPM.

PREFERRED QUALIFICATIONS:

CCDS certification preferred at hire.
Previous CDS experience preferred.
Minimum 5 years short term acute medical/surgical hospital nursing experience.
BSN or RN with BS in applicable field.
Minimum of two years CDI experience.
Preferred CCDS or CDIP certification.
Knowledge of payment methodologies and CMS/AHRQ Quality metrics.
Working knowledge of Epic EMR and Nuance CDE One.
5+ years of adult acute care experience in Med/surg, critical care, emergency room, or PACU

For Skilled Nursing Facility Only:

Understand Medicare Part A guidelines.
Understand the current FY SNF PPS Final Rule.
Understand the CMS Clinical Category Crosswalk tool for PDPM ICD-10-CM Mappings.
Understand the MDS Resident Assessment Instrument (RAI) Manual.
Ability to use the CMS PDPM Calculator Tool.

Required Licensure/Certification:

Current professional licensure in the state of New York based on degree. Foreign Medical Graduate (FMG) MD Prepared License not required.
Effective as of 03/02/2026, Effective 3 years from hire, CCDS certification required.

For Skilled Nursing Facility Only:

Current professional licensure in the state of New York based on degree. Foreign Medical Graduate (FMG) MD Prepared License is not required.
CCDS certification is not required.

EDUCATION:

LICENSES / CERTIFICATIONS:

PHYSICAL REQUIREMENTS:

S - Sedentary Work - Exerting up to 10 pounds of force occasionally Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.

For disease specific care programs refer to the program specific requirements of the department for further specifications on experience and educational expectations, including continuing education requirements.

Any physical requirements reported by a prospective employee and/or employee’s physician or delegate will be considered for accommodations.

PAY RANGE:

$78,000.00 - $96,200.00

CITY:

Rochester

POSTAL CODE:

14626

The listed base pay range is a good faith representation of current potential base pay for a successful full time applicant. It may be modified in the future and eligible for additional pay components. Pay is determined by factors including experience, relevant qualifications, specialty, internal equity, location, and contracts.

Rochester Regional Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, creed, religion, sex (including pregnancy, childbirth, and related medical conditions), sexual orientation, gender identity or expression, national origin, age, disability, predisposing genetic characteristics, marital or familial status, military or veteran status, citizenship or immigration status, or any other characteristic protected by federal, state, or local law.

Quick Apply

Refine Your Search

clinical documentation specialist jobs in rochester, ny

Clinical Documentation Specialist

Clinical Document Spec

RN, Clinical Document Spec

Medical Coding Specialist

Per Diem Clinical Research Nurse - Home Visits

Clinical Research Regulatory Specialist II

Coder - Inpatient

Credentialing Administrator I

Human Subject Research Specialist II

Outcomes Specialist I, CHeT

Human Subject Research Specialist I

Credentialing Coordinator

Sr Human Subject Research Specialist

Mohs Surgery Nurse (RN/LPN)

Sr. Reg Affairs & Compl Spec

Pediatric Registered Nurse (Community-based)

Sr Clin Research Reg Supt Spec

Registered Nurse

REGISTERED NURSE - FLEX

Lab Registration and Billing Specialist - RGH (Full-Time, Days)

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