Clinical Documentation Specialist

SUMMARY The CDS 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. STATUS: Full-time LOCATION: Remote DEPARTMENT: Clinical Documentation SCHEDULE: Day shift ATTRIBUTES u2022 Ability to learn/develop the skills necessary to perform the CDS roleu2022 Organizational, analytical, writing and interpersonal skills u2022 Dependable, self-directed and pleasant u2022 Critical thinking, problem solving and deductive reasoning skills u2022 Knowledge of Pathophysiology and Disease Process u2022 Basic Computer skills u2013 familiarity with Windows based software programs u2022 Knowledge of regulatory environment u2022 Understand and support CDS documentation strategies (upon completion of training) u2022 Understand and communicate differences between Medicare Part A and Part B guidelines and how they impact DRG assignments (upon completion of training) u2022 Knowledge of Core Measure and Patient Safety Indicators (upon completion of training) - For Skilled Nursing Facility Only:a. Understand Medicare Part A guidelinesb. Understand the current FY SNF PPS Final Rulec. Understand the CMS Clinical Category Crosswalk tool for PDPM ICD-10-CM Mappingsd. Understand the MDS Resident Assessment Instrument (RAI) Manuale. Ability to use the CMS PDPM Calculator Tool Minimum Qualifications: u2022 3-5 years of adult acute care experience in med/surg., critical care, emergency room, or PACU. u2022 Registered nursing degree required, BSN preferred. Other clinical education may be considered, such as PA, NP, or MD. u2022 Previous CDS experience preferred - For Skilled Nursing Facility Only:a. 3 years of patient care, or CDI or Coding experience in an adult population, acute care or skilled nursing facilityb. Registered Nursing Degree required, BSN preferred, or other clinical education may be considered such as LPN, PA, NP, or MD.OR a degree in Health Information Management (Associateu2019s Degree with RHIT; Bacheloru2019s Degree with RHIA) Required Licensure/Certification: RN, PA, NP, MBBS or MD prepared candidates.If hired after January 1, 2017: Must obtain CCDS certification within 30 months of hire. For Skilled Nursing Facility Only:Valid RN or LPN license, or other applicable professional license, or RHIT, or RHIA Rochester General Health is an Equal Opportunity / Affirmative Action Employer. Minority/Female/Disability/Veteran RESPONSIBILITIES + u2022 Reviews medical record for completeness and accuracy for severity of illness (SOI), risk of mortality (ROM), complexity of care, and quality u2022 Accurate and timely record review u2022 Recognize opportunities for documentation improvement u2022 Formulate clinically credible documentation clarifications u2022 Request documentation clarifications as appropriate for SOI, ROM, Complexity of Care, Core Measures, and Patient Safety u2022 Effective and appropriate communication with physicians u2022 Provides education to members of the patient care team regarding the CDS process. u2022 Timely follow up on all cases and resolution of those with clinical documentation clarifications u2022 Actively participate in Team Meetings u2022 Manage multiple priorities u2022 Communicates with HIM staff and resolves discrepancies u2022 Accurate input of data into department software - For Skilled Nursing Facility Only: a. Utilize the ICD-10-CM Official Guidelines for Coding & Reporting and their application in the long-term healthcare setting.b. Utilize an ICD-10-CM indexing system to determine appropriate ICD-10-CM codes.c. 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. EDUCATION: LICENSES / CERTIFICATIONS: RN - Registered Nurse - New York State Education Department (NYSED) 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 employeeu2019s physician or delegate will be considered for accommodations. PAY RANGE: $78,000.00 - $95,000.00 CITY: Rochester POSTAL CODE: 14621 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.

Created: 2026-02-16