Clinical Documentation Specialist Jobs in USA 2025

The primary tertiary care provider in the Queens borough is Elmhurst Hospital Center (EHC). The hospital is a Level I Trauma Center, an Emergency Heart Care Station, and a 911 Receiving Hospital, with a total of 545 beds. It is the preeminent health care organization in critical areas, including Surgery, Cardiology, Women’s Health, Pediatrics, Rehabilitation Medicine, Renal, and Mental Health Services.

Our goal at NYC Health + Hospitals is to consistently provide exceptional health services. Through empathic communication and partnerships with all individuals, each employee adopts a person-centered approach that demonstrates the ICARE values of Integrity, Compassion, Accountability, Respect, and Excellence.

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Work Shifts

8:00 A.M – 4:00 P.M

Job Description

Under the supervision of the Director of Clinical Documentation, Director of Health Information Management, or a designee for revenue management and recovery, the individual facilitates and obtains appropriate physician documentation for clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of patient care.

This is done to optimize reimbursement, ensure patient-centered quality care, optimal utilization of resources, service delivery, and compliance with NYC Health + Hospitals, the hospital, and all relevant regulatory policies, procedures, and standards of care to improve patient experience and achieve better outcomes. Maintains current knowledge of all relevant regulations and the clinical documentation field, as well as effective communication, planning, and organizational skills. Within this category of positions, there are two (2) Assignment Levels; all personnel are authorized to perform tasks remotely and conduct related work.

Assignment Level I

Performs designated responsibilities regarding the review, reporting, processing, and quality assurance of clinical documentation under the supervision of a supervisor. Assignment Level I typically involves the following tasks:

Duties & Responsibilities of Clinical Documentation Specialist Jobs in USA 2025

• Enhances the overall quality, completeness, accuracy, specificity, and timeliness of physician clinical record documentation by utilizing computer programs and systems, conducting an extensive medical record review, and engaging in effective communication with the appropriate clinical and coding staff.
• Through extensive ongoing communication with physicians, other patient caregivers, and medical records coding staff, obtains appropriate physician documentation for clinical conditions or procedures to ensure that the clinical documentation accurately captures information describing patients’ acuity, severity of illness, and risk of mortality.
• Supports appropriate reimbursement for the level of service rendered to all patients and reflects the appropriate, complete, and accurate level of service delivered to patients.
• Conducts concurrent and retrospective reviews of patient records for a specific patient population to assess documentation in order to assign the principal diagnosis, pertinent secondary diagnoses, postadmission complications, and procedures for accurate Diagnosis-Related Group (DRG) assignment and Case Mix Index (CMI), risk of mortality, and severity of illness.
• In order to resolve and elucidate conflicting information in the patient’s medical record prior to discharge, the individual queries clinicians for incomplete, inconsistent, unclear, or conflicting health record documentation. Additionally, the individual maintains a record of query and review activities and other pertinent records.
• Conducts a follow-up review of the patient medical record and provides feedback to ensure that any clarifications have been addressed and recorded in the patient’s chart.
• Additionally, assigns a working/updated or final DRG upon patient discharge and prior to final coding and quality reporting submissions, as required.
• Reports and identifies areas of vulnerability that may affect financial opportunities, and collaborates with Finance or other relevant personnel to resolve issues.
• Engages in the analysis and trending of statistical data for specific patient populations to identify opportunities for improvement.
• Assists in the preparation and presentation of clinical documentation monitoring/trending reports for the review of physicians and hospital leadership.
• Provides ongoing guidance and mentoring, as needed, and assists in the orientation and training of new staff members.
• Provides ongoing education to providers regarding compliance and reimbursement issues, as well as appropriate clinical documentation and coding guidelines and practices. Provides guidance on the effect of provider documentation on the accurate reporting of a patient’s clinical information and reimbursement.
• Attends and/or participates in staff, departmental, and interdisciplinary meetings, as well as quality assurance/performance improvement (QA/PI) activities, training, and LEAN efficiency/process improvement events.
• Executes additional tasks that are pertinent to the task at hand.

Minimum Qualifications

Request for Assignment Level I Appointment:

• A foreign medical graduate with two (2) years of experience in medical records review or utilization and case management; or 5. Successful completion of an educational program that culminates in a medical degree, followed by two (2) years of experience, as per the aforementioned.
• A valid New York State license and current registration to practice as a Registered Professional Nurse (RN) issued by the New York State Education Department (NYSED), a Bachelor of Science in Nursing degree from an accredited institution or university, and four (4) years of acute care experience; or
• A valid New York State license and current registration to practice as a Nurse Practitioner (NP) issued by the NYSED, as well as two (2) years of experience, as described in “1” above; or
• Two (2) years of experience, as described in “1” above, and a valid New York State license and current registration to practice as a Physician Assistant (PA) issued by the NYSED; or

Beenfits of Clinical Documentation Specialist Jobs in USA

• Job Security and High Demand: The demand for CDS personnel is on the rise as a result of the growing emphasis on the provision of accurate medical documentation for the purposes of compliance, invoicing, and quality care.
• Possibilities for Remote Employment: Remote or hybrid work options are available in numerous CDS positions, which enable professionals to work from home while still making a meaningful contribution to healthcare organizations.
• Enhancement of Patient Care Quality: In order to enhance patient care, CDS professionals are essential in ensuring that medical records are accurate, comprehensive, and representative of the care provided.
• Beneficial Effect on Financial Results: CDS specialists assist healthcare organizations in optimizing reimbursement and reducing claim denials by guaranteeing precise documentation.
• Acknowledgment of Professional: The healthcare industry holds the position of a Clinical Documentation Specialist in high regard due to its significance and complexity.
• Work-Life Balance: In contrast to other healthcare positions that offer irregular shifts, many CDS positions provide predictable schedules, frequently with standard working hours, which can contribute to a more favorable work-life balance.
• Effect on Regulatory Compliance: CDS professionals assist healthcare organizations in adhering to the regulations established by agencies such as The Joint Commission and CMS (Centers for Medicare & Medicaid Services).
• Contribution to Data Analysis and Research: Accurate clinical documentation is indispensable for data analysis, public health reporting, and research.
• Minimal Patient Interaction: CDS careers offer a chance to contribute to patient care without direct patient interaction for those who prefer non-clinical roles in healthcare.
• Personal Satisfaction: The capacity to enhance healthcare delivery through precise documentation can be personally gratifying for CDS personnel, as they are aware that their efforts have a positive impact on patient care and organizational success.

How To Apply

To apply for this position, please submit your application online by selecting the “Apply for Job” option.

NYC Health and Hospitals provides a benefits bundle that is both competitive and comprehensive, which includes:

• Comprehensive health benefits are provided to employees who are employed for a minimum of 20 hours per week.
• Pension Plans and Retirement Savings
• Eligible employees may participate in loan forgiveness programs.
• Paid vacation and holidays in accordance with the collectively bargained contracts of employees
• Professional development opportunities and discounts on college tuition
• Numerous employee incentive programs

Frequently Asked Questions: