Clinical Documentation Specialist

Rochester Regional Health • Muscatine, IA

1d • $78,000 - $96,200 • Remote

About The Position

The Clinical Documentation Specialist facilitates accurate medical-record documentation regarding severity of illness, expected risk of mortality, complexity of care, and quality. The role involves extensive record review and interaction with healthcare and ancillary teams. The position is based at Unity Hospital and is listed as remote, with a 40-hour workweek on Monday through Friday in eight-hour shifts.

For skilled nursing facility work, the role also applies ICD-10-CM coding guidance in the long-term healthcare setting and collaborates with hospital and SNF teams to support specified, appropriate, and billable diagnosis codes for SNF authorizations and PPS assessments under PDPM.

The position requires an appropriate clinical degree and current New York professional licensure based on degree, subject to the stated exception for foreign medical graduate MD-prepared candidates. The posting describes experience and certification requirements, including a CCDS certification requirement effective three years from hire, with separate certification provisions for SNF-only work. The annual pay range is $78,000 to $96,200.

Requirements

• Registered nursing degree required; other clinical education may be considered, including PA, NP, MD, or foreign medical graduate MD preparation.
• Effective 03/02/2026, active unrestricted RN candidates or other specified clinicians must have at least five years of adult acute-care experience in med/surg, critical care, emergency room, or PACU.
• Candidates without certification must complete the CCDS or CDIP certification exam after completing two years of full-time-equivalent CDS hours and pass within six months of eligibility.
• Current professional licensure in New York based on degree; a license is not required for foreign medical graduate MD-prepared candidates.
• Effective three years from hire, CCDS certification is required, except for SNF-only work, where CCDS certification is not required.
• For SNF-only work, effective 03/02/2026, 2–3 years of experience with SNF payment methodologies and PDPM.

Nice To Haves

• CCDS certification preferred at hire.
• Previous CDS experience preferred.
• At least five years of short-term acute medical/surgical hospital nursing experience.
• BSN or RN with a BS in an applicable field.
• At least two years of CDI experience.
• CCDS or CDIP certification preferred.
• Knowledge of payment methodologies and CMS/AHRQ quality metrics.
• Working knowledge of Epic EMR and Nuance CDE One.
• Five or more years of adult acute-care experience in med/surg, critical care, emergency room, or PACU.
• For SNF-only work, understanding of Medicare Part A guidelines.
• For SNF-only work, understanding of the current fiscal-year SNF PPS Final Rule.
• For SNF-only work, understanding of the CMS Clinical Category Crosswalk tool for PDPM ICD-10-CM mappings.
• For SNF-only work, understanding of the MDS Resident Assessment Instrument (RAI) Manual.
• For SNF-only work, ability to use the CMS PDPM Calculator Tool.

Responsibilities

• Review medical records for completeness and accuracy regarding severity of illness, risk of mortality, complexity of care, and quality.
• Complete record reviews accurately and in a timely manner.
• Recognize opportunities for documentation improvement.
• Formulate clinically credible documentation clarifications.
• Request documentation clarifications as appropriate for severity of illness, risk of mortality, complexity of care, Core Measures, and patient safety.
• Communicate effectively and appropriately with physicians.
• Educate patient-care team members about the CDS process.
• Follow up on cases in a timely manner and resolve cases involving clinical documentation clarifications.
• Actively participate in team meetings.
• Manage multiple priorities.
• Communicate with HIM staff and resolve discrepancies.
• Enter data accurately into department software.
• For SNF-only work, use ICD-10-CM Official Guidelines for Coding & Reporting and apply them in the long-term healthcare setting.
• For SNF-only work, use an ICD-10-CM indexing system to determine appropriate codes.
• For SNF-only work, collaborate with hospital and SNF team members to ensure documentation supports specified, appropriate, and billable ICD-10-CM codes for primary and secondary diagnoses for SNF authorization and PPS assessments required under PDPM.

What This Job Offers

• Job Type: Full-time
• Education Level: Associate degree