RN Clinical Documentation Improvement Specialist

United Health Services • Binghamton, NY

16h • $37 - $56 • Onsite

About The Position

The Clinical Documentation Improvement (CDI) Specialist-RN is a registered nurse responsible for performing concurrent and retrospective reviews of inpatient medical records to ensure complete, accurate, and compliant clinical documentation. This role focuses on supporting accurate ICD 10 CM/PCS coding, MS DRG assignment, severity of illness (SOI), risk of mortality (ROM), quality reporting, and reimbursement integrity. This role works closely with providers, coders, and quality teams to clarify documentation and support accurate data capture for clinical, financial, and regulatory reporting. This role applies clinical knowledge and critical thinking skills to identify documentation gaps and facilitate timely, compliant provider clarification.

Requirements

• Associate’s Degree in Nursing (ASN) or Nursing Diploma
• Valid NYS RN licensure or eligible

Nice To Haves

• Bachelor’s Degree in Nursing (BSN)
• Working knowledge of encoding system and Excel
• Previous Coding experience
• CCS (Certified Coding Specialist) – AHIMA
• CIC (Certified Inpatient Coder)-AAPC
• CCDS (Certified Clinical Documentation Specialist)–ACDIS

Responsibilities

• Performing concurrent and retrospective reviews of inpatient medical records
• Ensuring complete, accurate, and compliant clinical documentation
• Supporting accurate ICD 10 CM/PCS coding, MS DRG assignment, severity of illness (SOI), risk of mortality (ROM), quality reporting, and reimbursement integrity
• Working closely with providers, coders, and quality teams to clarify documentation
• Supporting accurate data capture for clinical, financial, and regulatory reporting
• Applying clinical knowledge and critical thinking skills to identify documentation gaps
• Facilitating timely, compliant provider clarification

Benefits

• Medical coverage
• Dental coverage
• Vision coverage
• Discounted childcare through Bright Horizons
• Pet insurance
• Legal services
• Identity theft protection
• PTO starts accruing from day one
• 403(b) retirement plan with company match
• Flexible spending accounts
• Access to financial advisors
• Up to $400/year in wellness rewards
• 24/7 EAP counseling
• Virtual mental health support
• Food pantry
• PTO donation program
• Professional attire through the Classy Closet
• Access to 100,000+ online courses
• Leadership programs
• Tuition reimbursement
• Clinical ladders
• Internal mobility

What This Job Offers

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