Clinical Document Spec

As a community, the University of Rochester is defined by a deep commitment to Meliora - Ever Better. Embedded in that ideal are the values we share: equity, leadership, integrity, openness, respect, and accountability. Together, we will set the highest standards for how we treat each other to ensure our community is welcoming to all and is a place where all can thrive. Job Location (Full Address): 601 Elmwood Ave, Rochester, New York, United States of America, 14642 Opening: Worker Subtype: Regular Time Type: Full time Scheduled Weekly Hours: 40 Department: 500009 Utilization Management Work Shift: UR - Day (United States of America) Range: UR URCE 215 Compensation Range: $81,310.00 - $105,703.00 _The referenced pay range represents the minimum and maximum compensation for this job. Individual annual salaries/hourly rates will be set within the job's compensation range, and will be determined by considering factors including, but not limited to, market data, education, experience, qualifications, expertise of the individual, and internal equity considerations._ Responsibilities: Facilitates clinical documentation improvement through concurrent and retrospective interaction with physicians and members of the healthcare team. This interaction supports the clinical severity of the inpatient admission, quality documentation standards that align with federal and state regulations and assists with maximizing revenue. Essential Functions: + Recognizes gaps and facilitates modifications in clinical documentation that support the accuracy of medical conditions for inpatient encounters. Recognizes documentation opportunities with the assistance of computer software. Conducts clinical documentation improvement efforts through query processes. + Provides oversight of EPARC, including UM and unbilled work queues. Communicates with individual physicians and medical team, providing guidance and clarification around principle diagnoses, complicating conditions, and diagnoses being treated to ensure complete and accurate documentation in the medical record. + Presents overall findings to key stakeholders, including leadership and peers. Provides education to peers and healthcare team members on documentation improvement, reimbursement opportunities, and overall performance. + Demonstrates knowledge of trends in clinical diagnoses that result in payer denials. Ensures the validity of data for reporting and measuring physician and hospital outcomes through software and data analysis. Audits clinical documentation to confirm points of clarification have been entered in the medical record. + Meets established productivity expectations of the CDI program. Maintains knowledge of hospital clinical practice guidelines to support the most thorough review of the medical record. + Other duties as assigned. Minimum Education & Experience: + Bachelor's degree in Nursing (BSN) and 5 years of inpatient clinical experience, knowledge of complex disease processes required OR + Bachelor's, Master's or Doctorate degree in a relevant clinical discipline: Prepared Physician Assistant (PA) or Nurse Practitioner (NP) or Bachelor of Medicine, Bachelor of Surgery (MBBS) or Doctor of Medicine/Osteopathic Medicine (MD/DO) and 5 years inpatient clinical experience, knowledge of complex disease processes required. + Or equivalent combination of education and experience. + Prior experience with EPARC, eRecord, HDM, and SharePoint preferred. Licenses and Certifications: + Registered Nurse License, current in NYS upon hire required or NP u2013 Nurse Practitioner license, current in NYS upon hire required or PA u2013 Physician Assistant license current in NYS upon hire required or MD - Doctor of Medicine - MD License current in NYS upon hire required or DO - Doctor of Osteopathic Medicine current DO License in NYS upon hire required AND Clinical Documentation Specialist (CDS) upon hire preferred or CDIP - Clinical Documentation Improvement Professional upon hire preferred The University of Rochester is committed to fostering, cultivating, and preserving an inclusive and welcoming culture to advance the Universityu2019s Mission to Learn, Discover, Heal, Create u2013 and Make the World Ever Better. In support of our values and those of our society, the University is committed to not discriminating on the basis of age, color, disability, ethnicity, gender identity or expression, genetic information, marital status, military/veteran status, national origin, race, religion, creed, sex, sexual orientation, citizenship status, or any other characteristic protected by federal, state, or local law (Protected Characteristics). This commitment extends to non-discrimination in the administration of our policies, admissions, employment, access, and recruitment of candidates, for all persons consistent with our values and based on applicable law. Notice: If you are a Current Employee, please log into myURHR to search for and apply to jobs using the Jobs Hub. Your application, if submitted using this portal, cannot be moved forward. Learn. Discover. Heal. Create. Located in western New York, Rochester is our namesake and our home. One of the worldu2019s leading research universities, Rochester has a long tradition of breaking boundariesu2014always pushing and questioning, learning and unlearning. We transform ideas into enterprises that create value and make the world ever better. If youu2019re looking for a career in higher education or health care, the University of Rochester may offer the perfect opportunity for your background and goals. At the University of Rochester, we are committed to fostering, cultivating, and preserving an inclusive and welcoming culture and are united by a strong commitment to be ever betteru2014Meliora. It is an ideal that informs our shared mission to ensure all members of our community feel safe, respected, included, and valued.

Created: 2026-03-19