RN, Clinical Document Spec

Rochester, NY


Clinical Documentation Specialist Job Description :

The Clinical Documentation Specialist (CDS) RN facilitates clinical documentation improvement through concurrent and retrospective review of the medical record. The CDS will work collaboratively with attending physicians and Health Information Management to clarify and identify gaps in the documentation for each patient encounter. This ultimately ensures the quality and integrity of the patient’s medical record. 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.

Qualification :

Licensed RN with a minimum of 5 years of advanced inpatient clinical expertise and extensive knowledge of complex disease processes. BSN preferred. If not obtained prior to hire, Clinical Documentation Specialist (CDS) or Clinical Documentation Improvement Practitioner (CDIP) certification is required following 2 years in the role and completed within 12 months thereafter.

The University of Rochester is committed to fostering, cultivating, and preserving a culture of equity, diversity, and inclusion to advance the University’s mission to Learn, Discover, Heal, Create – 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 status protected by law. This commitment extends to the administration of our policies, admissions, employment, access, and recruitment of candidates from underrepresented populations, veterans, and persons with disabilities consistent with these values and government contractor Affirmative Action obligations.

How To Apply

All applicants must apply online.

EOE Minorities/Females/Protected Veterans/Disabled

Pay Range

Pay Range: $77,667 - $108,784 Annually

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.

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Location: Strong Memorial Hospital
Full/Part Time: TAR