Northwell Health · 17 hours ago
Clinical Documentation Specialist (RN - CDIP/CCDS Cert)
Lake Success, NY
Full-time
Onsite
Entry, Mid Level
$78K/yr - $130K/yr
1+ years expNorthwell Health is a leading healthcare provider, and they are seeking a Clinical Documentation Specialist. The role involves facilitating and obtaining accurate clinical documentation to support the severity of illness and complexity of care, while collaborating with physicians to ensure completeness and accuracy of medical records.
ConsultingHealth CareHealth DiagnosticsMedicalPublishing
Responsibilities
Facilitates clarification of clinical documentation ensuring accuracy and integrity in the medical record
Facilitates appropriate clinical documentation to support diagnosis coding and ensure the appropriate level of service is recorded
Works with physicians on assigned patient care units to clarify clinical documentation in the patient’s medical record through a concurrent review process throughout the patient’s inpatient stay
Requests clarification of clinical documentation from the physician(s) on a concurrent basis as needed to ensure documentation is complete and accurate prior to discharge
Ensures the level of service rendered to patients, and the patient’s severity of illness is accurately documented and recorded
Follows up on CDI queries as needed to ensure appropriate documentation is recorded in the medical record
Interacts with physicians as needed to discuss and advise on clinical documentation requirements and provides timely and accurate responses to clinical documentation and coding questions
Demonstrates knowledge of ICD-10 CM and ICD-10 PCS coding, MS-DRG and APR NY and APR National grouper logic, documentation opportunities, clinical documentation requirements, and compliance to regulatory and facility policies and procedures
Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient’s chart
Reconciles reviewed cases to update any changes in status, procedures/treatments, and confer with providers to finalize diagnoses
Educates medical staff on clinical documentation opportunities that impacts the accuracy of the medical record
Inputs outcome data in the CDI software to be able to track response to queries. Responsible for file maintenance including entry into database for tracking and trending audit results. Communicate findings of potential or missed diagnoses and the revenue impact that were discovered during the chart audit
Regularly exercises independent judgment on matters of significance within defined procedures to determine appropriate actions/approaches
Understands department, division, corporate strategy and operating objectives, including impacts
Normally receives general instructions on routine work, detailed instructions on new projects or assignments
Majority of contact is within own function, area, or department and may be customer service oriented
Performs related duties as required. All responsibilities noted here are considered essential functions of the job under the Americans with Disabilities Act. Duties not mentioned here but considered related are not essential functions
Qualification
Required
Graduate from an accredited School of Nursing required
Must obtain a Bachelor of Science in Nursing degree within 5 years of employment date
Current License to practice as a Registered Professional Nurse in New York State required
Specialized certifications as needed (CCEDS and CCS)
1-3 years of relevant experience required
Company
Northwell Health
Northwell Health is New York State’s largest health care provider and private employer, with 28 hospitals, about 1,000+ outpatient facilities and more than 16,000 affiliated physicians.
10001+ employees
H1B Sponsorship
Northwell Health has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2021 (18)
2020 (13)
Funding
Current Stage
Late StageTotal Funding
$58.3MKey Investors
National Institute of Mental HealthNational Human Genome Research InstituteBreakthrough Discoveries
2025-12-02Grant· $4M
2025-10-23Grant· $3.2M
2025-06-16Grant· $2.3M
Leadership Team
Michael Dowling
President and CEO
Nick Stefanizzi
Chief Executive Officer at Northwell Direct
Recent News
Morningstar.com
2025-12-15
Company data provided by crunchbase