Clinical Documentation Specialist Jobs in New York
Clinical Documentation Specialist jobs in New York are in strong demand, concentrated across major academic medical centers, large health systems, and specialty hospitals, with openings at every level from entry-level coders to senior CDI program leads. New York City, Albany, and Buffalo account for the heaviest hiring activity, anchored by institutions like NewYork-Presbyterian, Northwell Health, and Montefiore Medical Center. The most sought-after specialties in New York include inpatient clinical documentation improvement, HCC coding for value-based care programs, and quality reporting. Find a role that fits below and apply directly.
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Showing 5 of 6+ Clinical Documentation Specialist jobs
Employment Type:
Full time
Shift:
Day Shift
Description:
RN Clinical Documentation Specialist
Full-time day shift
St. Peter's Hospital in Albany, NY
Position Highlights:
- Recognized leader: Magnet Hospital in the Capital Region
- Quality of Life: Where career opportunities and quality of life converge
- Advancement: Strong orientation program, generous tuition allowance and career development
What you will do:
The Clinical Documentation Specialist utilizes advanced clinical and coding expertise to direct efforts toward the integrity of clinical documentation through the roles of reviewer, educator and consultant. Facilitates the overall quality, completeness, accuracy and integrity of medical record documentation through extensive record review.
Through extensive interaction with physicians and other members of the healthcare team, achieves appropriate clinical documentation to support code assignment, medical necessity, severity of illness, risk of mortality and level of services rendered to all patients. Participates in the development and delivery of education for providers and members of the healthcare team.
PRIMARY JOB RESPONSIBILITIES AND DUTIES:
- Knows, understands, incorporates, and demonstrates the Trinity Health Mission, Vision, and Values in behaviors, practices, standards, policies, procedures and decisions.
- Demonstrates understanding of appropriate clinical documentation, to ensure that the severity of illness, risk of mortality and level of services provided are accurately reflected in the health record.
- Assists in overall quality, timeliness and completeness of the health record to ensure appropriate data, provider communication and quality outcomes.
- Serves as a resource for appropriate clinical documentation.
- Communicates with and educates physicians and all other members of the healthcare team regarding clinical documentation and monitors provider engagement.
- Identifies learning opportunities for healthcare providers.
- Conducts concurrent reviews of selected patient health records to address legibility, clarity, completeness, consistency and precision of clinical documentation.
- Formulates compliant clarifications/queries following Trinity Health’s documentation integrity procedures.
- Interacts with physicians, nurses and ancillary staff regarding compliant documentation requirements, clarification/query requests and educational opportunities.
- Accurately codes all relevant, appropriate and compliant working diagnoses codes, establishing a working principle diagnosis and working DRG (MS or APR).
- Collaborates with coding staff to ensure documentation of discharge diagnoses and co-morbidities are a complete reflection of the patient’s clinical status and care.
- Resolves all discrepancies in a courteous manner.
- Demonstrates expertise in problem-solving skills based on theoretical knowledge, clinical experience and sound judgement and serves as a professional role model by demonstrating desirable practice behaviors.
- Proficient with leveraging the functions of 3M/360 for entering data related to CDI efficiencies and effectiveness.
- Performs other duties as assigned by leadership.
- Maintains a working knowledge of applicable Federal, State and local laws and regulations, accrediting agencies, Trinity Health’s Organizational Integrity Program, Standards of Conduct, Code of Ethics, as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical and professional behavior.
MINIMUM QUALIFICATIONS, REQUIRED KNOWLEDGE, SKILLS AND ABILITIES:
Must possess an Associate/Diploma Degree in Nursing, or Health Information Technology (HIT) OR an Advanced degree in nursing or medical field such as NP/APN or PA.
Must possess one of the below:
- Current Registered Nurse License
- Registered Health Information Administrator (RHIA)
- Registered Health Information Technician (RHIT)
- Certified Coding Specialist (CCS) required
- Licensure as a physician assistant (PA) or Nurse Practitioner/Advanced Practice Nurse (NP/APN) or completion of medical school.
Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Professional (CDIP) preferred. Two (2) years experience in Critical Care, Medical or Surgical Inpatient Care Nursing, as an RN, physician assistant (PA), nurse practitioner/advanced practice nurse (NP/APN), medical school graduate or as an inpatient coder preferred. Excellent communication (verbal and written), interpersonal, collaboration and relationship-building skills. Strong critical thinking skills and ability to integrate knowledge. Prioritization and organizational skills required. Effective presentation/facilitation skills to accomplish educational goals for all members of the healthcare team. Demonstrated ability to use a standard desktop and Windows based computer system, including a basic understanding of email, internet and computer navigation. Ability to use other software as required to perform the essential functions on the job. Experience with databases, spreadsheet software and presentation software preferred. Accurate data entry skills and typing skills at minimum 30 wpm. Must be comfortable operating independently and in a collaborative environment. Must possess a personal presence that is characterized by a sense of honesty, integrity and caring with the ability to inspire and motivate others to promote the philosophy, mission, vision, goals and values of Trinity Health.
PHYSICAL AND MENTAL REQUIREMENTS AND WORKING CONDITIONS:
Must be able to set and organize own work priorities and adapt to them as they change frequently. Must be able to work concurrently on a variety of tasks/projects in an environment that may be stressful with individuals having diverse personalities and work styles. Must possess the ability to comply with Trinity Health policies and procedures. Must be able to spend majority of work time utilizing a computer, monitor and keyboard. Must be able to work with interruptions and perform detailed tasks. The position requires the ability to concentrate and read for long periods of time. Ability to work in an onsite and virtual environment.
REPORTING RELATIONSHIPS:
Reports directly to the Regional CDI Manager
Has no responsibility for the supervision of staff.
Pay Range: $31.50 - $47.97
Pay is based on experience, skills, and education. Exempt positions under the Fair Labor Standards Act (FLSA) will be paid within the base salary equivalent of the stated hourly rates. The pay range may also vary within the stated range based on location.
Our Commitment
Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.
Employment Type:
Full time
Shift:
Day Shift
Description:
RN Clinical Documentation Specialist
Full-time day shift
St. Peter's Hospital in Albany, NY
Position Highlights:
- Recognized leader: Magnet Hospital in the Capital Region
- Quality of Life: Where career opportunities and quality of life converge
- Advancement: Strong orientation program, generous tuition allowance and career development
What you will do:
The Clinical Documentation Specialist utilizes advanced clinical and coding expertise to direct efforts toward the integrity of clinical documentation through the roles of reviewer, educator and consultant. Facilitates the overall quality, completeness, accuracy and integrity of medical record documentation through extensive record review.
Through extensive interaction with physicians and other members of the healthcare team, achieves appropriate clinical documentation to support code assignment, medical necessity, severity of illness, risk of mortality and level of services rendered to all patients. Participates in the development and delivery of education for providers and members of the healthcare team.
PRIMARY JOB RESPONSIBILITIES AND DUTIES:
- Knows, understands, incorporates, and demonstrates the Trinity Health Mission, Vision, and Values in behaviors, practices, standards, policies, procedures and decisions.
- Demonstrates understanding of appropriate clinical documentation, to ensure that the severity of illness, risk of mortality and level of services provided are accurately reflected in the health record.
- Assists in overall quality, timeliness and completeness of the health record to ensure appropriate data, provider communication and quality outcomes.
- Serves as a resource for appropriate clinical documentation.
- Communicates with and educates physicians and all other members of the healthcare team regarding clinical documentation and monitors provider engagement.
- Identifies learning opportunities for healthcare providers.
- Conducts concurrent reviews of selected patient health records to address legibility, clarity, completeness, consistency and precision of clinical documentation.
- Formulates compliant clarifications/queries following Trinity Health’s documentation integrity procedures.
- Interacts with physicians, nurses and ancillary staff regarding compliant documentation requirements, clarification/query requests and educational opportunities.
- Accurately codes all relevant, appropriate and compliant working diagnoses codes, establishing a working principle diagnosis and working DRG (MS or APR).
- Collaborates with coding staff to ensure documentation of discharge diagnoses and co-morbidities are a complete reflection of the patient’s clinical status and care.
- Resolves all discrepancies in a courteous manner.
- Demonstrates expertise in problem-solving skills based on theoretical knowledge, clinical experience and sound judgement and serves as a professional role model by demonstrating desirable practice behaviors.
- Proficient with leveraging the functions of 3M/360 for entering data related to CDI efficiencies and effectiveness.
- Performs other duties as assigned by leadership.
- Maintains a working knowledge of applicable Federal, State and local laws and regulations, accrediting agencies, Trinity Health’s Organizational Integrity Program, Standards of Conduct, Code of Ethics, as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical and professional behavior.
MINIMUM QUALIFICATIONS, REQUIRED KNOWLEDGE, SKILLS AND ABILITIES:
Must possess an Associate/Diploma Degree in Nursing, or Health Information Technology (HIT) OR an Advanced degree in nursing or medical field such as NP/APN or PA.
Must possess one of the below:
- Current Registered Nurse License
- Registered Health Information Administrator (RHIA)
- Registered Health Information Technician (RHIT)
- Certified Coding Specialist (CCS) required
- Licensure as a physician assistant (PA) or Nurse Practitioner/Advanced Practice Nurse (NP/APN) or completion of medical school.
Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Professional (CDIP) preferred. Two (2) years experience in Critical Care, Medical or Surgical Inpatient Care Nursing, as an RN, physician assistant (PA), nurse practitioner/advanced practice nurse (NP/APN), medical school graduate or as an inpatient coder preferred. Excellent communication (verbal and written), interpersonal, collaboration and relationship-building skills. Strong critical thinking skills and ability to integrate knowledge. Prioritization and organizational skills required. Effective presentation/facilitation skills to accomplish educational goals for all members of the healthcare team. Demonstrated ability to use a standard desktop and Windows based computer system, including a basic understanding of email, internet and computer navigation. Ability to use other software as required to perform the essential functions on the job. Experience with databases, spreadsheet software and presentation software preferred. Accurate data entry skills and typing skills at minimum 30 wpm. Must be comfortable operating independently and in a collaborative environment. Must possess a personal presence that is characterized by a sense of honesty, integrity and caring with the ability to inspire and motivate others to promote the philosophy, mission, vision, goals and values of Trinity Health.
PHYSICAL AND MENTAL REQUIREMENTS AND WORKING CONDITIONS:
Must be able to set and organize own work priorities and adapt to them as they change frequently. Must be able to work concurrently on a variety of tasks/projects in an environment that may be stressful with individuals having diverse personalities and work styles. Must possess the ability to comply with Trinity Health policies and procedures. Must be able to spend majority of work time utilizing a computer, monitor and keyboard. Must be able to work with interruptions and perform detailed tasks. The position requires the ability to concentrate and read for long periods of time. Ability to work in an onsite and virtual environment.
REPORTING RELATIONSHIPS:
Reports directly to the Regional CDI Manager
Has no responsibility for the supervision of staff.
Pay Range: $31.50 - $47.97
Pay is based on experience, skills, and education. Exempt positions under the Fair Labor Standards Act (FLSA) will be paid within the base salary equivalent of the stated hourly rates. The pay range may also vary within the stated range based on location.
Our Commitment
Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.
See All 6 Clinical Documentation Specialist Jobs in New York
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Find JobsClinical Documentation Specialist Jobs by City in New York
Where New York roles are concentrated, by current openings.
Clinical Documentation Specialist Job Market in New York
A snapshot from current New York openings, updated as new roles post.
Who's Hiring
- Catholic Health System1
- Newark Wayne Community Hospital1
- Northwell Health1
- SUNY Upstate Medical University1
- Trinity Health1
Top Industries Hiring
- Healthcare & Medical Services5
- Science & Research2
- Education1
What New York Employers Look For
The qualifications that appear most often in clinical documentation specialist jobs across New York.
- Registered Health Information Technician or Registered Health Information Administrator credential preferred by New York employers
- Minimum two years of clinical documentation or medical coding experience in an acute care setting
- Proficiency in ICD-10-CM and ICD-10-PCS coding systems with demonstrated accuracy
- Experience using electronic health record platforms such as Epic or Cerner
- Knowledge of clinical documentation improvement methodology and DRG optimization
- Strong written communication skills for concurrent physician query completion and response tracking
Clinical Documentation Specialist Jobs in New York: Frequently Asked Questions
How do you become a clinical documentation specialist in New York?
The standard path in New York is to earn a health information management or nursing degree, gain clinical or coding experience, and then obtain a nationally recognized credential such as the Certified Clinical Documentation Specialist from the Association of Clinical Documentation Integrity Specialists or the Registered Health Information Technician through AHIMA. New York does not issue a state-specific license for this role, so employers rely on these national credentials as the primary benchmark for hiring decisions.
How much do clinical documentation specialists make in New York?
Clinical documentation specialists in New York earn a median of about $61,720 a year, based on May 2025 Bureau of Labor Statistics wage data, ranging from around $40,730 for the lowest 10% to over $101,940 for the top 10%. Pay rises with experience, specialty, and employer.
Which companies hire clinical documentation specialists in New York?
Employers hiring clinical documentation specialists in New York right now include Catholic Health System, Newark Wayne Community Hospital, and Northwell Health, based on current listings on Migrate Mate as of June 2026. New York's density of large academic medical centers and regional health systems means steady openings across both inpatient hospital settings and affiliated outpatient networks throughout the state.
Which New York cities have the most clinical documentation specialist jobs?
Albany, Buffalo, and Lake Success have the most clinical documentation specialist openings in New York. New York City leads because of its concentration of major academic medical centers and multi-hospital health systems, while Albany and Buffalo generate consistent demand through regional health networks and state government-affiliated facilities that require ongoing documentation compliance and quality reporting support.
Are there remote clinical documentation specialist jobs in New York?
Yes, and more than most clinical roles. About 67% of clinical documentation specialist openings tied to New York are remote or hybrid as of June 2026, reflecting how much of the work involves chart review and physician querying through electronic health records rather than bedside presence. Concurrent review and coding audit functions are the positions most frequently posted as fully remote.
How can I get hired as a clinical documentation specialist in New York with little or no experience?
The most realistic entry path is transitioning from a medical coding or health information management role, both of which are well-represented in New York's large hospital systems. Northwell Health and NewYork-Presbyterian run structured health information and coding associate programs that accept candidates with an RHIT credential and limited hands-on experience. Earning the CCDS credential while working as a coder or clinical data analyst strengthens a candidate's profile considerably for New York employers making their first CDI hire.
Where can I find and apply to clinical documentation specialist jobs in New York?
You can find and apply to clinical documentation specialist jobs in New York on Migrate Mate, which lists current New York openings. Search the listings for roles that match your experience and specialty, then apply directly to the ones that fit.
See All 6 Clinical Documentation Specialist Jobs in New York
Find roles in New York that match your experience and apply in just a few clicks.
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