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RN, Clinical Document Spec

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University of Rochester

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Location:
United States of America , Rochester

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Category:
Nursing

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Contract Type:
Not provided

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Salary:

81310.00 - 105703.00 USD / Year
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Job Description:

Facilitates clinical documentation improvement through concurrent and retrospective interaction with physicians and members of the healthcare team. This interaction supports the clinical severity of the inpatient admission, quality documentation standards that align with federal and state regulations and assists with maximizing revenue.

Job Responsibility:

  • Facilitates clinical documentation improvement through concurrent and retrospective interaction with physicians and members of the healthcare team
  • Recognizes gaps and facilitates modifications in clinical documentation that support accuracy of medical conditions for inpatient encounter
  • Recognizes documentation opportunities with the assistance of computer software
  • Conducts clinical documentation improvement efforts through query processes
  • Provides oversight for EPARC, including UM work queues and unbilled work queues
  • Communicates with individual physicians and medical team, providing guidance and clarification around principal diagnoses, complicating conditions, and diagnoses being treated to ensure complete and accurate documentation in medical record
  • Presents overall findings to key stakeholders, including leadership and peers
  • Provides education to peers and healthcare team members for documentation improvement, reimbursement opportunities, and overall performance improvement
  • Demonstrates knowledge of trends in clinical diagnoses that results in payer denials
  • Ensures validity of data for reporting and measuring physician and hospital outcomes using computer software and analysis of data
  • Audits clinical documentation to confirm points of clarification have been entered in the medical record
  • Meets established productivity expectations of CDI program
  • Maintains knowledge of hospital clinical practice guidelines to support the most thorough review of the medical record

Requirements:

  • Associate's degree Registered Nurse (RN) required
  • Bachelor's degree in Nursing preferred
  • 5 years inpatient clinical experience, knowledge of complex disease processes required
  • Or equivalent combination of education and experience
  • Prior experience with EPARC, eRecord, HDM, Cobius, and Sharepoint preferred
  • Current RN License in NYS upon hire required

Nice to have:

  • Bachelor's degree in Nursing
  • Prior experience with EPARC, eRecord, HDM, Cobius, and Sharepoint

Additional Information:

Job Posted:
February 21, 2026

Employment Type:
Fulltime
Work Type:
Remote work
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