What You'll Do
As a Clinical Documentation Specialist, you will play a key role in refining how patient care is documented across inpatient settings. You’ll identify gaps in medical records and work directly with physicians and clinical staff to ensure diagnoses, treatments, and complications are clearly and accurately recorded. Using query processes, you’ll resolve ambiguities and support complete documentation that reflects the true complexity of patient conditions.
You will monitor and manage workflows in EPARC, including utilization management and unbilled case tracking, while ensuring data integrity for performance measurement and reporting. Regular communication with providers helps align documentation with clinical facts and regulatory standards. You’ll also share insights with leadership and contribute to education initiatives that improve team understanding of documentation best practices, reimbursement implications, and quality metrics.
Through audits and data analysis, you’ll verify that clarifications are properly entered and maintain awareness of evolving clinical trends that impact payer decisions. Your work supports regulatory compliance, revenue integrity, and accurate representation of patient severity.
Requirements
- Associate’s degree or equivalent combination of education and experience
- Current New York State RN license required at time of hire
- Five years of inpatient clinical experience
- Strong understanding of complex disease processes and clinical workflows
- Familiarity with federal and state documentation regulations
Preferred Qualifications
- Bachelor’s degree in Nursing
- Experience with EPARC, eRecord, HDM, Cobius, or SharePoint systems
Work Environment
This is an onsite position located at 601 Elmwood Ave, Rochester. The role operates within a culture grounded in equity, integrity, respect, and accountability. Leadership and openness are valued, with a strong institutional commitment to inclusion and non-discrimination across all protected characteristics.
Compensation
Salary range: $81,310 – $105,703 per year.
