Clinical Documentation Specialist
About The Position
Thompson Health is seeking a Clinical Documentation Specialist (CDS Nurse) to review medical records and support clinical documentation improvement. The role is remote, with potential occasional onsite meeting requirements; hospital orientation is required in person. Applicants must be residents of New York State. The schedule is Monday through Friday. Pay ranges from $35.00 to $45.00 per hour, with starting pay based on experience. The role works with interdisciplinary teams and supports documentation integrity, medical necessity, diagnosis-related groups, quality of care, compliance, and appropriate financial reimbursement. The position also includes educating providers, nurses, and CDI staff. Thompson Health describes its culture as empowering, collaborative, and supportive of employee growth and contributions.
Requirements
- Licensed RN or equivalent, or higher education in a health-related field.
- Minimum of five years of inpatient clinical experience in an acute hospital setting.
- Working knowledge of federal and state regulations.
- Ensure clinical documentation integrity supports medical necessity, diagnosis-related groups (DRGs), and quality of care.
- Ability to work independently, prioritize, and effectively identify and resolve problems.
- Ability to develop and maintain collaborative working relationships with diverse disciplines.
- Extensive knowledge of complex disease processes.
- Obtain Clinical Documentation Specialist (CDS) or Clinical Documentation Improvement Practitioner (CDIP) credential within three years of starting the role.
- Proficiency with computers, spreadsheets, and Microsoft Office.
- Must be a New York State resident.
Nice To Haves
- Critical care experience.
- Clinical Documentation Improvement experience.
- Epic experience.
- Bachelor of Science in Nursing preferred, or obtained within five years of hire; alternatively, college graduation in another health-related field.
Responsibilities
- Perform extensive medical record reviews using CDI software integrated with the EMR.
- Facilitate documentation improvement by participating in committee meetings.
- Assist in coordinating clinical documentation improvement in accordance with corporate compliance guidelines and appropriate financial reimbursement.
- Provide education to providers, nurses, and other CDI staff.
Benefits
- Health, dental, and vision insurance.
- Tuition reimbursement up to $6,000 per year.
- Contribution and match on retirement plan.
- Five weeks of paid time off.
- Access to Success coaches.
- Free parking.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
