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Clinical Document Spec
Career Insights for Clinical Documentation Specialist
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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 the U.S.
+4% projected growth
Job Description
- Ever Better. Embedded in that ideal are the values we share: equity, leadership, integrity, openness, respect, and accountability. Together, we will set the highest standards for how we treat each other to ensure our community is welcoming to all and is a place where all can thrive.
- Job Location (Full Address):
- 601 Elmwood Ave, Rochester, New York, United States of America, 14642
Opening:
Worker Subtype:
Regular Time Type:
Full timeScheduled Weekly Hours:
40Department:
500009Utilization Management Work Shift:
UR- Day (United States of America)
Range:
UR URCD 215
Compensation Range:
$81,307.00- $109,761.00 _The referenced pay range represents the minimum and maximum compensation for this job. Individual annual salaries/hourly rates will be set within the job's compensation range, and will be determined by considering factors including, but not limited to, market data, education, experience, qualifications, expertise of the individual, and internal equity considerations._
Responsibilities:
- Facilitates clinical documentation improvement through concurrent and retrospective interaction with physicians and members of the healthcare team. This interaction supports the clinical severity of the inpatient admission, quality documentation standards that align with federal and state regulations and assists with maximizing revenue.
Essential Functions:
- + Recognizes gaps and facilitates modifications in clinical documentation that support the accuracy of medical conditions for inpatient encounters.
Minimum Education & Experience:
- + Bachelor's degree in Nursing (BSN) and 5 years of inpatient clinical experience, knowledge of complex disease processes required OR + Bachelor's, Master's or Doctorate degree in a relevant clinical discipline: Prepared Physician Assistant (PA) or Nurse Practitioner (NP) or Bachelor of Medicine, Bachelor of Surgery (MBBS) or Doctor of Medicine/Osteopathic Medicine (MD/DO) and 5 years inpatient clinical experience, knowledge of complex disease processes required.
Licenses and Certifications:
- + Registered Nurse License, current in NYS upon hire required or NP
- Nurse Practitioner license, current in NYS upon hire required or PA
- Physician Assistant license current in NYS upon hire required or MD
- Doctor of Medicine
- MD License current in NYS upon hire required or DO
- Doctor of Osteopathic Medicine current DO License in NYS upon hire required AND Clinical Documentation Specialist (CDS) upon hire preferred or CDIP
- Clinical Documentation Improvement Professional upon hire preferred The University of Rochester is committed to fostering, cultivating, and preserving an inclusive and welcoming culture to advance the University's Mission to Learn, Discover, Heal, Create
- and Make the World Ever Better.
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- Learn. Discover. Heal. Create.
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