Clinical Documentation Improvement Specialist (Hybrid)

A health system in Westchester is seeking a Clinical Documentation Improvement Specialist to join its Health Information Management team. This position offers a hybrid schedule and the opportunity to collaborate with clinical teams to improve documentation accuracy, quality outcomes, and patient care. The Clinical Documentation Improvement Specialist will be responsible for:Reviewing medical records to ensure accurate, complete clinical documentation reflecting severity of illness and quality of careIdentifying documentation gaps and submitting clarification queries to physicians and other providersCollaborating with physicians, nursing, coding, and HIM teams to improve documentation accuracy and appropriate diagnosis codingSupporting accurate DRG assignment, risk adjustment, and quality reporting through concurrent and retrospective chart reviewsParticipating in staff education and clinical documentation improvement initiatives RequirementsBachelor's Degree in Nursing (BSN) Active NYS RN license required4–6 years of adult acute care experience in Medical/Surgical, Critical Care, Emergency Department, or PACU settingsStrong clinical knowledge of disease processes, coding guidelines, DRGs, and clinical documentation requirements; must achieve a minimum score of 70% on the Clinical Competency Assessment Compensation: $95,000 to $143,000 annually