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 9+ Clinical Documentation Specialist jobs
Job Title: Clinical Documentation Specialist
Department: Clinical Documentation Improvement
Location: Unity Hospital (Remote)
Hours Per Week: 40 hours per week
Schedule: Monday- Friday 8 hr. shifts.
SUMMARY:
The role facilitates accurate documentation for severity of illness, expected risk of mortality, complexity of care and quality in the medical record. This involves extensive record review and interaction with members of the healthcare team and ancillary teams.
RESPONSIBILITIES:
- Reviews medical record for completeness and accuracy for severity of illness (SOI), risk of mortality (ROM), complexity of care, and quality.
- Accurate and timely record review.
- Recognize opportunities for documentation improvement.
- Formulate clinically credible documentation clarifications.
- Request documentation clarifications as appropriate for SOI, ROM, Complexity of Care, Core Measures, and Patient Safety.
- Effective and appropriate communication with physicians.
- Provides education to members of the patient care team regarding the CDS process.
- Timely follow up on all cases and resolution of those with clinical documentation clarifications.
- Actively participate in Team Meetings.
- Manage multiple priorities.
- Communicates with HIM staff and resolves discrepancies.
- Accurate input of data into department software.
For Skilled Nursing Facility Only:
- Utilize the ICD-10-CM Official Guidelines for Coding & Reporting and their application in the long-term healthcare setting.
- Utilize an ICD-10-CM indexing system to determine appropriate ICD-10-CM codes.
- Collaborate with the hospital and skilled nursing facility (SNF) team members to ensure documentation supports the most specified, appropriate, and billable ICD-10-CM code(s) for primary and secondary diagnoses (co-morbidities) to be assigned for a SNF authorization, and PPS assessments required under PDPM.
MINIMUM QUALIFICATIONS:
- Registered nursing degree required, other clinical education may be considered, such as PA, NP, MD or Foreign Medical Graduate (FMG) MD prepared.
- Effective as of 03/02/2026, will consider active unrestricted RN candidates (or other clinicians as defined below) with at least 5 years of adult acute care experience in med/surg, critical care, emergency room, or PACU.
- If no certification, must complete CCDS or CDIP certification exam after completing two years full time equivalent of CDS hours. Must pass certification exam within 6 months of eligibility.
For Skilled Nursing Facility Only:
- Registered nursing degree required, other clinical education may be considered, such as PA, NP, or MD or Foreign Medical Graduate (FMG) MD prepared.
- Effective as of 03/02/2026, will consider active unrestricted RN candidates (or other clinicians as defined below) with at least 5 years of adult acute care experience in med/surg, critical care, emergency room, or PACU.
- Effective as of 03/02/2026, 2-3 years' experience with SNF payment methodologies and PDPM.
PREFERRED QUALIFICATIONS:
- CCDS certification preferred at hire.
- Previous CDS experience preferred.
- Minimum 5 years short term acute medical/surgical hospital nursing experience.
- BSN or RN with BS in applicable field.
- Minimum of two years CDI experience.
- Preferred CCDS or CDIP certification.
- Knowledge of payment methodologies and CMS/AHRQ Quality metrics.
- Working knowledge of Epic EMR and Nuance CDE One.
- 5+ years of adult acute care experience in Med/surg, critical care, emergency room, or PACU
For Skilled Nursing Facility Only:
- Understand Medicare Part A guidelines.
- Understand the current FY SNF PPS Final Rule.
- Understand the CMS Clinical Category Crosswalk tool for PDPM ICD-10-CM Mappings.
- Understand the MDS Resident Assessment Instrument (RAI) Manual.
- Ability to use the CMS PDPM Calculator Tool.
Required Licensure/Certification:
- Current professional licensure in the state of New York based on degree. Foreign Medical Graduate (FMG) MD Prepared License not required.
- Effective as of 03/02/2026, Effective 3 years from hire, CCDS certification required.
For Skilled Nursing Facility Only:
- Current professional licensure in the state of New York based on degree. Foreign Medical Graduate (FMG) MD Prepared License is not required.
- CCDS certification is not required.
EDUCATION:
LICENSES / CERTIFICATIONS:
PHYSICAL REQUIREMENTS:
S - Sedentary Work - Exerting up to 10 pounds of force occasionally Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.For disease specific care programs refer to the program specific requirements of the department for further specifications on experience and educational expectations, including continuing education requirements.
Any physical requirements reported by a prospective employee and/or employee’s physician or delegate will be considered for accommodations.
PAY RANGE:
$78,000.00 - $96,200.00CITY:
POSTAL CODE:
The listed base pay range is a good faith representation of current potential base pay for a successful full time applicant. It may be modified in the future and eligible for additional pay components. Pay is determined by factors including experience, relevant qualifications, specialty, internal equity, location, and contracts.
Rochester Regional Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, creed, religion, sex (including pregnancy, childbirth, and related medical conditions), sexual orientation, gender identity or expression, national origin, age, disability, predisposing genetic characteristics, marital or familial status, military or veteran status, citizenship or immigration status, or any other characteristic protected by federal, state, or local law.
Job Title: Clinical Documentation Specialist
Department: Clinical Documentation Improvement
Location: Unity Hospital (Remote)
Hours Per Week: 40 hours per week
Schedule: Monday- Friday 8 hr. shifts.
SUMMARY:
The role facilitates accurate documentation for severity of illness, expected risk of mortality, complexity of care and quality in the medical record. This involves extensive record review and interaction with members of the healthcare team and ancillary teams.
RESPONSIBILITIES:
- Reviews medical record for completeness and accuracy for severity of illness (SOI), risk of mortality (ROM), complexity of care, and quality.
- Accurate and timely record review.
- Recognize opportunities for documentation improvement.
- Formulate clinically credible documentation clarifications.
- Request documentation clarifications as appropriate for SOI, ROM, Complexity of Care, Core Measures, and Patient Safety.
- Effective and appropriate communication with physicians.
- Provides education to members of the patient care team regarding the CDS process.
- Timely follow up on all cases and resolution of those with clinical documentation clarifications.
- Actively participate in Team Meetings.
- Manage multiple priorities.
- Communicates with HIM staff and resolves discrepancies.
- Accurate input of data into department software.
For Skilled Nursing Facility Only:
- Utilize the ICD-10-CM Official Guidelines for Coding & Reporting and their application in the long-term healthcare setting.
- Utilize an ICD-10-CM indexing system to determine appropriate ICD-10-CM codes.
- Collaborate with the hospital and skilled nursing facility (SNF) team members to ensure documentation supports the most specified, appropriate, and billable ICD-10-CM code(s) for primary and secondary diagnoses (co-morbidities) to be assigned for a SNF authorization, and PPS assessments required under PDPM.
MINIMUM QUALIFICATIONS:
- Registered nursing degree required, other clinical education may be considered, such as PA, NP, MD or Foreign Medical Graduate (FMG) MD prepared.
- Effective as of 03/02/2026, will consider active unrestricted RN candidates (or other clinicians as defined below) with at least 5 years of adult acute care experience in med/surg, critical care, emergency room, or PACU.
- If no certification, must complete CCDS or CDIP certification exam after completing two years full time equivalent of CDS hours. Must pass certification exam within 6 months of eligibility.
For Skilled Nursing Facility Only:
- Registered nursing degree required, other clinical education may be considered, such as PA, NP, or MD or Foreign Medical Graduate (FMG) MD prepared.
- Effective as of 03/02/2026, will consider active unrestricted RN candidates (or other clinicians as defined below) with at least 5 years of adult acute care experience in med/surg, critical care, emergency room, or PACU.
- Effective as of 03/02/2026, 2-3 years' experience with SNF payment methodologies and PDPM.
PREFERRED QUALIFICATIONS:
- CCDS certification preferred at hire.
- Previous CDS experience preferred.
- Minimum 5 years short term acute medical/surgical hospital nursing experience.
- BSN or RN with BS in applicable field.
- Minimum of two years CDI experience.
- Preferred CCDS or CDIP certification.
- Knowledge of payment methodologies and CMS/AHRQ Quality metrics.
- Working knowledge of Epic EMR and Nuance CDE One.
- 5+ years of adult acute care experience in Med/surg, critical care, emergency room, or PACU
For Skilled Nursing Facility Only:
- Understand Medicare Part A guidelines.
- Understand the current FY SNF PPS Final Rule.
- Understand the CMS Clinical Category Crosswalk tool for PDPM ICD-10-CM Mappings.
- Understand the MDS Resident Assessment Instrument (RAI) Manual.
- Ability to use the CMS PDPM Calculator Tool.
Required Licensure/Certification:
- Current professional licensure in the state of New York based on degree. Foreign Medical Graduate (FMG) MD Prepared License not required.
- Effective as of 03/02/2026, Effective 3 years from hire, CCDS certification required.
For Skilled Nursing Facility Only:
- Current professional licensure in the state of New York based on degree. Foreign Medical Graduate (FMG) MD Prepared License is not required.
- CCDS certification is not required.
EDUCATION:
LICENSES / CERTIFICATIONS:
PHYSICAL REQUIREMENTS:
S - Sedentary Work - Exerting up to 10 pounds of force occasionally Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.For disease specific care programs refer to the program specific requirements of the department for further specifications on experience and educational expectations, including continuing education requirements.
Any physical requirements reported by a prospective employee and/or employee’s physician or delegate will be considered for accommodations.
PAY RANGE:
$78,000.00 - $96,200.00CITY:
POSTAL CODE:
The listed base pay range is a good faith representation of current potential base pay for a successful full time applicant. It may be modified in the future and eligible for additional pay components. Pay is determined by factors including experience, relevant qualifications, specialty, internal equity, location, and contracts.
Rochester Regional Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, creed, religion, sex (including pregnancy, childbirth, and related medical conditions), sexual orientation, gender identity or expression, national origin, age, disability, predisposing genetic characteristics, marital or familial status, military or veteran status, citizenship or immigration status, or any other characteristic protected by federal, state, or local law.
See All 9 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
Top Industries Hiring
- Healthcare & Medical Services
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, FutureSight, and Oneida Health, based on current listings on Migrate Mate as of August 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?
Bronx, Melville, and Oneida 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 August 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 9 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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