Clinical Documentation Specialist- HIM

NYU Langone Health
September 22, 2022
United States
Job Type
Work Setting


We have an exciting opportunity to join our team as a Clinical Documentation Specialist- HIM.

In this role, the successful candidate as the Clinical Documentation Specialist is responsible for improving the overall quality and completeness of clinical documentation. Facilitates modifications to clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, and medical records coding staff. Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes.
Work closely with Coding to assist and/or coordinate in resolving documentation and coding issues. Participate in training to clinicians and provide ongoing support.
Ensure that documentation practices and processes comply with applicable regulatory guidelines and requirements. Participate in special projects when necessary.

Job Responsibilities

  • Manage other assignments and projects as assigned.
  • Participate in the daily operations and activities of the CDI program to continually improve documentation.
  • Utilize documentation tools on an ongoing basis.
  • Regularly and effectively communicate with clinical staff, including physicians.
  • Collaborate with Coding in an effort to maintain coding and documentation quality and compliance. Ensures that coding process and guidelines meet State and Federal requirements and standards.
  • Works with the medical staff to continuously improve clinical documentation to facilitate accurate coding through the use of physician query when appropriate.
  • Facilitates communication of various professionals to support organizational goals related to compliance, quality and coding.
  • Assists in development of education for both clinical and non-clinical staff.
  • Meets performance standards by setting goals and objectives, prioritizing work, and using available resources efficiently and effectively.
  • Stays abreast of the latest developments, advancements, and trends in the field of documentation improvement and coding by attending seminars/workshops, reading professional journals, actively participating in professional organizations, and maintaining certification or licensure. Integrates knowledge gained into current work practices.
  • Participates in the training of new employees as needed.
  • Ensures that work is completed accurately and according to schedule.

Minimum Qualifications

To qualify you must have a Current nursing (RN) license with a Bachelor’s Degree in Nursing, Bachelor’s degree with current certification (RHIA, RHIT, and/or CCS), and/or graduate education leading to MD, DO, or equivalent degree required.
2 years of experience in acute care, health care administration or commensurate experience.
CCDS within one year of hire for all candidates. Experience with ICD-10 coding and DRG assignment.
Good oral and written communication skills. Excellent interpersonal skills.
Demonstrated knowledge and clinical experience relevant to clinical and regulatory aspects of care and reimbursement..

Required Licenses

Reg Health Info Tech-RHIT, Reg Health Info Admin-RHIA, Registered Nurse License-NYS

Preferred Qualifications

HIM or related field experience. 2 years of clinical documentation improvement experience.

Qualified candidates must be able to effectively communicate with all levels of the organization.

NYU Langone Health provides its staff with far more than just a place to work. Rather, we are an institution you can be proud of, an institution where you’ll feel good about devoting your time and your talents.

NYU Langone Health is an equal opportunity and affirmative action employer committed to diversity and inclusion in all aspects of recruiting and employment. All qualified individuals are encouraged to apply and will receive consideration without regard to race, color, gender, gender identity or expression, sex, sexual orientation, transgender status, gender dysphoria, national origin, age, religion, disability, military and veteran status, marital or parental status, citizenship status, genetic information or any other factor which cannot lawfully be used as a basis for an employment decision. We require applications to be completed online.

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