University of Rochester

Lead Clinical Document Spec

University of Rochester$87K — $122K *
Hospitals & Medical Centers
5 - 7 years of experience
Job Overview by Ladders

Qualifications

  • Bachelor's degree in Nursing (BSN) or relevant clinical discipline with 6 years inpatient experience.
  • 2 years of Clinical Documentation Improvement expertise in acute care.
  • Knowledge of complex disease processes.
  • Leadership experience preferred.
  • Registered Nurse, NP, PA, MD, or DO license current in NYS upon hire required.
  • Certification as Clinical Documentation Specialist (CDS) or Clinical Documentation Improvement Professional (CDIP) upon hire required.

Responsibilities

  • Incorporates Clinical Documentation Improvement Nurse functions with staff coordination and training.
  • Conducts medical record reviews to identify documentation improvement opportunities.
  • Monitors staff workflows, productivity, and assists with education on documentation standards.
  • Facilitates leadership support and co-planning of evaluations with management.
  • Participates in data collection and fosters collaboration with interdisciplinary teams to resolve discrepancies.
  • Represents CDI in meetings and leads documentation refinement initiatives.
  • Completes other duties as assigned.

Benefits

  • Health insurance coverage, including medical, dental, and vision plans.
  • Flexible scheduling and promotional opportunities.
  • Engagement in continuous professional development and support for certifications.
  • Access to hospital committees and interdisciplinary collaborations.
  • Timely feedback and recognition programs for staff contributions.
Full Job Description
Job Location (Full Address):

601 Elmwood Ave, Rochester, New York, United States of America, 14642

Opening:

Worker Subtype:
Regular

Time Type:
Full time

Scheduled Weekly Hours:
40

Department:
500009 Utilization Management

Work Shift:
UR - Day (United States of America)

Range:
UR URCE 216

Compensation Range:
$87,708.00 - $122,792.00

The referenced pay range represents the minimum and maximum compensation for this job. Individual annual salaries/hourly rates will be set within the job's compensation range, and will be determined by considering factors including, but not limited to, market data, education, experience, qualifications, expertise of the individual, and internal equity considerations.

Responsibilities:

Incorporates the job functions of the Clinical Documentation Improvement Nurse with additional responsibilities of coordinating staff assignments, education, training, and supporting day-to-day CDI operations. Supports the clinical severity of inpatient admission and quality documentation standards that align with federal and state regulations. Assists with maximizing revenue.

Essential Functions:
  • Directly participates in CDI assignments, serving as a clinical resource. Conducts complex medical record reviews to identify documentation improvement opportunities (e.g., for PSI, VBP, HAC, readmissions, PDX clarification). Develops effective physician queries. Monitors query rates and assists with project initiatives to enhance workflows and reporting outcomes.
  • Supports and monitors staff workflows, productivity, and quality. Works with management to develop and monitor performance indicators related to the revenue cycle and quality outcomes. Maintains high customer service standards and assists with staff education on documentation, ICD-10, and IPPS updates. Participates in continuous professional development.
  • Facilitates leadership support by giving input on daily operations, co-planning evaluations, modeling organizational behaviors (URMC/ICARE), and fostering trusting relationships. Recognizes staff, rounds for outcomes, provides timely feedback, assists with scheduling and accountability, facilitates staff meetings, participates in hospital committees, drives change, and onboards new team members.
  • Contributes to broader hospital and departmental goals by participating in data collection, fostering interdisciplinary collaboration with various departments (e.g., physicians, Quality, HIM, Denials Management), ensuring adherence to regulatory guidelines and internal policies, and acting as a liaison to resolve documentation discrepancies. Represents CDI perspectives in interdisciplinary meetings and participates in hospital projects. Works collaboratively to analyze and report metrics to service lines. Leads processes improvement initiatives for documentation refinement.
  • Other duties as assigned.


Minimum Education & Experience:
  • Bachelor's degree in Nursing (BSN) and 6 years of inpatient clinical experience, knowledge of complex disease processes, including 2 years of Clinical Documentation Improvement expertise in acute care required OR
  • Bachelor's, Master's or Doctorate degree in a relevant clinical discipline: Prepared Physician Assistant (PA) or Nurse Practitioner (NP) or Bachelor of Medicine, Bachelor of Surgery (MBBS) or Doctor of Medicine/Osteopathic Medicine (MD/DO) and 6 years inpatient clinical experience, knowledge of complex disease processes, including 2 years of Clinical Documentation Improvement expertise in acute care required.
  • Or equivalent combination of education and experience.
  • Leadership experience preferred.


Knowledge, Skills & Abilities:
  • Knowledge of hospital databases such as EPARC, eRecord, SharePoint, Iodine, 3M preferred.


Licenses and Certifications:
  • Registered Nurse License, current in NYS upon hire required or NP - Nurse Practitioner license, current in NYS upon hire required or PA - Physician Assistant license current in NYS upon hire required or MD - Doctor of Medicine - MD License current in NYS upon hire required or DO - Doctor of Osteopathic Medicine current DO License in NYS upon hire required AND Clinical Documentation Specialist (CDS) upon hire required or CDIP - Clinical Documentation Improvement Professional upon hire required

About University of Rochester

The University of Rochester is a private research university located in Rochester, New York. It was founded in 1850 and has since grown to become one of the top universities in the United States. The university offers undergraduate, graduate, and doctoral programs in a wide range of fields, including business, engineering, humanities, and social sciences. The university is known for its strong research programs, particularly in the fields of optics, photonics, and imaging. The university has a diverse student body and is committed to providing a high-quality education to all of its students.
Learn more about University of Rochester
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