Clinical Documentation Specialist

Rochester Regional Health

Clinical Documentation Specialist improving medical records for Rochester Regional Health, an integrated healthcare services organization. Reviewing documentation, clarifying diagnoses, and supporting coding, quality, and reimbursement.

Posted 8/12/2026full-timeRemote • New York • 🇺🇸 United StatesMid-LevelSenior💰 $78,000 - $96,200 per yearWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates expertise in clinical documentation improvement, including ICD-10-CM coding and payment methodologies, while effectively communicating with healthcare teams to enhance documentation accuracy and quality. Holds a registered nursing degree and relevant certifications, ensuring compliance with industry standards and regulations.

Highest-signal resume keywords

ICD-10-CM CodingClinical Documentation Improvement (CDI)Registered Nursing DegreeCCDS or CDIP CertificationExperience with SNF Payment Methodologies

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical Documentation ImprovementICD-10-CM CodingData EntryMedical Record ReviewPayment Methodologies KnowledgeCMS Quality Metrics KnowledgeMDS RAI Manual KnowledgePDPM AssessmentsDocumentation ClarificationClinical Care Complexity Assessment

Soft Skills

Effective CommunicationTeam CollaborationEducation and TrainingProblem SolvingPrioritization

Tools & Technologies

Epic EMRNuance CDE OneCMS PDPM Calculator Tool

Certifications & Qualifications

Registered Nurse LicenseCCDS CertificationCDIP Certification

Industry Keywords

Skilled Nursing Facility (SNF)Medicare Part A GuidelinesCMS Clinical Category CrosswalkSNF PPS Final RuleAdult Acute Care Experience

About the role

Key responsibilities & impact

Facilitate accurate documentation for severity of illness, expected risk of mortality, complexity of care, and quality in medical records
Review medical records for completeness and accuracy
Identify opportunities for documentation improvement
Formulate and request clinically credible documentation clarifications
Communicate effectively with physicians and healthcare and ancillary teams
Educate patient care team members about the CDS process
Follow up on cases and resolve clinical documentation clarifications
Participate in team meetings and manage multiple priorities
Communicate with HIM staff and resolve discrepancies
Enter data accurately into department software
For Skilled Nursing Facility: apply ICD-10-CM coding guidelines and indexing systems
For Skilled Nursing Facility: collaborate with hospital and SNF teams to support specified, appropriate, and billable ICD-10-CM codes and PDPM assessments

Requirements

What you’ll need

Registered nursing degree required; other clinical education may be considered, including PA, NP, MD, or FMG MD preparation
Active unrestricted RN or other qualifying clinician status with at least 5 years of adult acute care experience in med/surg, critical care, emergency room, or PACU, effective 03/02/2026
CCDS or CDIP certification exam required within six months of eligibility if not certified; CCDS certification required three years from hire, effective 03/02/2026
For Skilled Nursing Facility: 2–3 years of experience with SNF payment methodologies and PDPM, effective 03/02/2026
Current professional licensure in New York State based on degree; FMG MD-prepared license not required
Minimum 5 years of short-term acute medical/surgical hospital nursing experience
Minimum 2 years of CDI experience
Knowledge of payment methodologies and CMS/AHRQ quality metrics
Working knowledge of Epic EMR and Nuance CDE One
For Skilled Nursing Facility: knowledge of Medicare Part A guidelines, SNF PPS Final Rule, CMS Clinical Category Crosswalk, MDS RAI Manual, and CMS PDPM Calculator Tool
Sedentary work capability, including occasional exertion of up to 10 pounds of force

Benefits

Comp & perks

🌐 Worldwide ❌ Jobs You've Hidden ⭐️ Saved Jobs ✅ Applied Jobs ✉️ Email Alerts 👤 Account Rochester Regional Health Website LinkedIn All Job Openings 10,000+ employees 🏥 Healthcare ⚕️ Healthcare Insurance 📚 Education Healthcare
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Education Rochester Regional Health is an integrated health services organization serving the people of Western New York. It operates multiple hospitals and healthcare facilities, providing a wide range of healthcare services, including emergency care, primary care, specialty clinics, and urgent care. The organization is committed to medical education and research, offering training programs, residencies, and clinical trials. Rochester Regional Health focuses on comprehensive care with emphasis on treating patients respectfully and meeting their diverse medical needs across all stages of life. Clinical Documentation Specialist 🔥 0 minutes ago 🗽 New York – Remote 💵 $78k - $96.2k / year ⏰ Full Time 🟡 Mid-level 🟠 Senior 🏥📝 Medical Writer Apply Now Customize resume + cover letter Report problem ☆ Save ☑️ Mark as applied ❌ Hide 📋 Description
Facilitate accurate documentation for severity of illness, expected risk of mortality, complexity of care, and quality in medical records
Review medical records for completeness and accuracy
Identify opportunities for documentation improvement
Formulate and request clinically credible documentation clarifications
Communicate effectively with physicians and healthcare and ancillary teams
Educate patient care team members about the CDS process
Follow up on cases and resolve clinical documentation clarifications
Participate in team meetings and manage multiple priorities
Communicate with HIM staff and resolve discrepancies
Enter data accurately into department software
For Skilled Nursing Facility: apply ICD-10-CM coding guidelines and indexing systems
For Skilled Nursing Facility: collaborate with hospital and SNF teams to support specified, appropriate, and billable ICD-10-CM codes and PDPM assessments 🎯 Requirements
Registered nursing degree required; other clinical education may be considered, including PA, NP, MD, or FMG MD preparation
Active unrestricted RN or other qualifying clinician status with at least 5 years of adult acute care experience in med/surg, critical care, emergency room, or PACU, effective 03/02/2026
CCDS or CDIP certification exam required within six months of eligibility if not certified; CCDS certification required three years from hire, effective 03/02/2026
For Skilled Nursing Facility: 2–3 years of experience with SNF payment methodologies and PDPM, effective 03/02/2026
Current professional licensure in New York State based on degree; FMG MD-prepared license not required
Minimum 5 years of short-term acute medical/surgical hospital nursing experience
Minimum 2 years of CDI experience
Knowledge of payment methodologies and CMS/AHRQ quality metrics
Working knowledge of Epic EMR and Nuance CDE One
For Skilled Nursing Facility: knowledge of Medicare Part A guidelines, SNF PPS Final Rule, CMS Clinical Category Crosswalk, MDS RAI Manual, and CMS PDPM Calculator Tool
Sedentary work capability, including occasional exertion of up to 10 pounds of force Apply Now 📊 Check your resume score for this job Improve your chances of getting an interview by checking your resume score before you apply. Check Resume Score Similar Jobs Medical Writer – Clinical Compliance 🔥 16 hours ago Solventum 10,000+ employees 🏥 Healthcare 📦 Logistics 💼 Consulting Website LinkedIn All Job Openings Medical Writer developing clinical evaluations and regulatory reports for Solventum, a healthcare solutions company. Supporting EU MDR compliance, audits, and medical-device lifecycle documentation. 🇺🇸 United States – Remote 💵 $124k - $170.5k / year ⏰ Full Time 🟡 Mid-level 🟠 Senior 🏥📝 Medical Writer RN Clinical Documentation Specialist Lead 🔥 21 hours ago Ochsner Health 10,000+ employees 🏥 Healthcare ⚕️ Healthcare Insurance 🤝 Non-profit Website LinkedIn All Job Openings RN clinical documentation lead reviewing inpatient records and guiding CDS staff. Supporting Ochsner Health, a major Gulf South not-for-profit healthcare provider. 🇺🇸 United States – Remote 💰 Grant on 2023-07 ⏰ Full Time 🟠 Senior 🏥📝 Medical Writer Clinical Documentation Integrity Manager 🔥 22 hours ago Guidehouse 10,000+ employees 🏥 Healthcare 🎖️ Defense 📦 Logistics Website LinkedIn All Job Openings Clinical Documentation Integrity Manager improving hospital documentation, coding accuracy, and CDI metrics for Guidehouse healthcare clients. Leading CDI teams, implementations, reporting, education, and physician engagement. 🇺🇸 United States – Remote 💵 $102k - $170k / year 💰 Grant on 2023-02 ⏰ Full Time 🟠 Senior 🔴 Lead 🏥📝 Medical Writer 🦅 H1B Visa Sponsor Clinical Documentation Specialist 🕒 Yesterday Tidelands Health 1001 - 5000 🏥 Healthcare ⚕️ Healthcare Insurance Website LinkedIn All Job Openings Clinical Documentation Specialist improving inpatient records for Tidelands Health, South Carolina’s nonprofit healthcare provider. Reviewing documentation, supporting coding accuracy and educating clinical staff. 🇺🇸 United States – Remote ⏰ Full Time 🟢 Junior 🟡 Mid-level 🏥📝 Medical Writer Clinical Documentation Specialist 🕒 Yesterday Tidelands Health 1001 - 5000 🏥 Healthcare ⚕️ Healthcare Insurance Website LinkedIn All Job Openings Clinical Documentation Specialist improving inpatient records for Tidelands Health, South Carolina’s largest nonprofit healthcare provider. Reviewing clinical documentation, supporting coding accuracy, and educating medical staff on documentation requirements. 🇺🇸 United States – Remote ⏰ Full Time 🟢 Junior 🟡 Mid-level 🏥📝 Medical Writer View More Medical Writer Jobs 🌐 Worldwide Built by Lior Neu-ner. I'd love to hear your feedback — Get in touch via DM or support@remoterocketship.com Search Search Jobs by country Search jobs by city Search jobs by job title Search entry-level jobs Search junior-level jobs Search senior-level jobs Search jobs by tech stack Search jobs by contract type Search remote internships Search remote part-time jobs Remote jobs Anywhere in the World Companies Hiring Anywhere in the World Companies Hiring Sales People Anywhere in the World Companies Hiring Software Engineers Anywhere in the World Resources Advice Tips for finding remote jobs Interview questions and answers Resume examples Cover letter examples Post a job Affiliates About us Is Remote Rocketship legit? Privacy policy Terms of service Job board SEO course Remote Job Search MasterClass AI Apply Copilot OpenClaw job finder Find jobs using your resume Jobs by Country Remote jobs anywhere in the world (Worldwide remote jobs) Remote jobs United States Remote jobs Australia Remote jobs Brazil Remote jobs Canada Remote jobs France Remote jobs Ireland Remote jobs Germany Remote jobs Netherlands Remote jobs Spain Remote jobs UK Popular Jobs Remote data analyst jobs Remote customer support jobs Remote executive assistant jobs Remote marketing jobs Remote product designer jobs Remote product manager jobs Remote project manager jobs Remote recruiter jobs Remote sales jobs Remote software engineer jobs Jobs by Type Remote full-time jobs Remote part-time jobs Remote contract jobs Remote internship jobs Remote entry-level jobs Remote jobs with no experience required Remote junior jobs (1-3 years of experience) Digital nomad jobs Remote jobs with no degree required Freelance remote jobs Temporary remote jobs Remote jobs hiring now Stay at home mom jobs