Rochester Regional Health · 7 hours ago
Clinical Documentation Specialist
Rochester, NY
Full-time
Onsite
Mid Level
$78K/yr - $96K/yr
3+ years expRochester Regional Health is a healthcare organization seeking a Clinical Documentation Specialist. The role involves facilitating accurate documentation for severity of illness, risk of mortality, and quality in medical records through extensive review and collaboration with healthcare professionals.
Health CareHospitalMedicalPrimary and Urgent CareWellness
Responsibilities
Reviews medical record for completeness and accuracy for severity of illness (SOI), risk of mortality (ROM), complexity of care, and quality
Accurate and timely record review
Recognize opportunities for documentation improvement
Formulate clinically credible documentation clarifications
Request documentation clarifications as appropriate for SOI, ROM, Complexity of Care, Core Measures, and Patient Safety
Effective and appropriate communication with physicians
Provides education to members of the patient care team regarding the CDS process
Timely follow up on all cases and resolution of those with clinical documentation clarifications
Actively participate in Team Meetings
Manage multiple priorities
Communicates with HIM staff and resolves discrepancies
Accurate input of data into department software
Utilize the ICD-10-CM Official Guidelines for Coding & Reporting and their application in the long-term healthcare setting
Utilize an ICD-10-CM indexing system to determine appropriate ICD-10-CM codes
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
Qualification
Required
3-5 years of adult acute care experience in med/surg., critical care, emergency room, or PACU
Registered nursing degree required, BSN preferred. Other clinical education may be considered, such as PA, NP, or MD
Previous CDS experience preferred
3 years of patient care, or CDI or Coding experience in an adult population, acute care or skilled nursing facility
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
RN, PA, NP, MBBS or MD prepared candidates
If hired after January 1, 2017: Must obtain CCDS certification within 30 months of hire
CCDS certification not required for legacy Unity team members hired before 12/31/2016
For Skilled Nursing Facility Only: Valid RN or LPN license, or another applicable professional license, or RHIT, or RHIA
Must obtain CCDS or CDIP certification within 30 months of hire
AS: Nursing (Required)
BLS - Basic Life Support - American Heart Association (AHA)
RN - Registered Nurse - New York State Education Department (NYSED)
Preferred
Previous CDS experience preferred
Company
Rochester Regional Health
Rochester Regional Health provides integrated health services.
10001+ employees
H1B Sponsorship
Rochester Regional 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
2025 (1)
2023 (3)
2022 (1)
2020 (2)
Funding
Current Stage
Late StageTotal Funding
$15.6MKey Investors
New York State Department of HealthMother Cabrini
2025-12-12Grant· $15M
2024-02-27Grant· $0.6M
Leadership Team
Richard Davis
CEO
Recent News
Rochester Business Journal
2025-12-25
Rochester Business Journal
2025-12-19
Rochester Business Journal
2025-11-07
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