RN Clinical Document Improvement Specialist

Position OverviewThe 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.

Primary Department, Division, or Unit:

Clinical Documentation Improvement, UHS Revenue Cycle Operations

Work Shift and Schedule:

This is a per diem position, which means you will work on an as needed, agreed upon basis. Working hours will be assigned by your manager.

Compensation Range:

$37.00 - $55.50 per hour, depending on experience

This position is not eligible for benefits.

-----

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 Coder)-AAPC
• CCDS (Certified Clinical Documentation Specialist)–ACDIS

-----

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. UHS provides healthcare and medical services for two-thirds of the region’s population, produces $1.3 billion a year in total economic impact, and boasts a workforce of more than 6,300 employees and providers. 

At UHS, our work is guided by our Values of Compassion, Trust, Respect, Teamwork, and Innovation. Whether you provide direct patient care or support behind the scenes, you are part of a shared purpose: to improve the health and well-being of the communities we serve. Every employee plays a meaningful role in fulfilling our mission—we’d love for you to consider joining us!

 

United Health Services is an Equal Opportunity Employer.