New York Licensed Clinical Documentation Specialist

Job Summary

To enhance clinical documentation accuracy, the full-time New York Licensed Clinical Documentation Specialist will review medical records for completeness, interact with healthcare teams, and provide education on documentation processes while working remotely.

Key responsibilities

• Review medical records for accuracy in severity of illness, risk of mortality, and complexity of care
• Request and formulate documentation clarifications in collaboration with healthcare providers
• Educate patient care team members about the clinical documentation improvement process

Required qualifications

• Registered nursing degree or equivalent clinical education (e.g., PA, NP, MD)
• At least 5 years of adult acute care experience in med/surg, critical care, emergency room, or PACU
• Completion of CCDS or CDIP certification exam within 6 months of eligibility after 2 years of full-time CDS hours
• Current professional licensure in the state of New York
• Experience with ICD-10-CM coding and clinical documentation improvement processes