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RN Clinical Documentation Improvement Specialist
Career Insights for Clinical Documentation Specialist
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Scorecard
Based on New York data
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What they do
A Clinical Documentation Specialist works with information technology systems and applications in health care organizations. Assists clinicians and staff with technology and implementing new systems. Creates systems for organizing and interpreting data and information for clinical trials. Records and manages clinical information about patients, including health assessments and diagnoses, test results, treatments, and follow up care requirements. Reviews and maintains patient records.
$83,383 / year median in New York
+4% projected growth
Job Description
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.Primary Department, Division, or Unit:
Facility Coding, UHS Revenue Cycle Operations Primary Work Shift:
Day Regular Scheduled Weekly Hours:
40Compensation Range:
$37.00- $55.50 per hour, depending on experience
Education/Experience Minimum Required:
Associate's Degree in Nursing (ASN) or Nursing Diploma.Preferred:
Bachelor's Degree in Nursing (BSN). Working knowledge of encoding system and Excel. Previous Coding experience.License/Certification Minimum Required:
Valid NYS RN licensure or eligible.Preferred:
CCS (Certified Coding Specialist)AHIMA CIC
(Certified Inpatient CoderAAPC CCDS
(Certified Clinical Documentation Specialist- ACDIS
- Why You'll Love Working at UHS At United Health Services (UHS), we believe every connection—to patients, to purpose, to each other—makes a difference. That's why we're intentional about supporting our team in ways that go beyond the job. Whether through meaningful benefits, personal growth, or fun along the way, we're here to help you thrive in work and life. A Culture of Connection
- We support each other like family and create space for every voice to be heard.
- We offer medical, dental, and vision coverage starting the first of the month after hire for employees working 24+ hours/week.
- From day one, PTO starts accruing so you can take time to recharge.
- With access to 100,000+ online courses, leadership programs, tuition reimbursement, clinical ladders, and internal mobility, we help you grow wherever your passion leads. We also continuously review compensation to ensure market competitiveness and internal equity, so you can feel confident your work is valued and rewarded fairly. A Place to Call Home
- Located in New York's Southern Tier, UHS offers more than a career—we offer a lifestyle. Enjoy four-season recreation, affordable living, top-rated schools, minor league sports, craft brews, a close-knit community, and more, all within reach of the Finger Lakes, the Catskills, and major Northeast cities.
- About United Health Services United Health Services (UHS) is a locally owned, not-for-profit healthcare system in New York's Southern Tier comprising four hospitals, long-term care and home care services, and physician practices in Broome and surrounding counties.
- United Health Services, Inc.