Senior Level Technical Documentation Specialist Jobs

Position Overview

The Clinical Documentation Improvement (CDI) Specialist – CDI-coder is responsible for performing concurrent and retrospective reviews of inpatient medical records to ensure complete, accurate, and compliant clinical documentation. This role focuses on supporting accurate ICD 10 CM/PCS coding, MS DRG assignment, severity of illness (SOI), risk of mortality (ROM), quality reporting, and reimbursement integrity. This role works closely with providers, coders, and quality teams to clarify documentation and support accurate data capture for clinical, financial, and regulatory reporting.

Primary Department, Division, or Unit:

Clinical Documentation Improvement, UHS Revenue Cycle Operations

Primary Work Shift:

Day

Regular Scheduled Weekly Hours:

40

Compensation Range:

$30.58 - $45.86 per hour, depending on experience

Job Responsibilities

Essential Functions:

• Review inpatient medical records concurrently and retrospectively to ensure accurate, complete, and compliant clinical documentation supporting ICD‑10 coding and DRG/APR assignments
• Write clear, clinically supported, and compliant provider queries to clarify diagnoses, procedures, and severity of illness in accordance with AHIMA and ACDIS guidelines
• Collaborate with physicians, coding professionals, and quality teams to improve documentation quality, data integrity, and clinical communication
• Apply clinical knowledge and coding standards to validate documentation supporting risk of mortality, severity of illness, and reimbursement accuracy
• Meet established productivity and accuracy benchmarks while maintaining attention to detail and regulatory compliance

Scope and Impact:

• Contribute directly to organizational quality outcomes, regulatory readiness, and revenue integrity through high-quality clinical documentation review
• Exercise independent judgment within defined guidelines to identify documentation gaps and recommend appropriate clarification
• Support department level performance improvement initiatives by analyzing documentation trends and opportunities for enhancement

Compliance and Professional:

• Maintain required certification(s) in accordance with job requirements and organizational policy
• Adhere to HIPAA, confidentiality, ethical coding standards, and organizational policies governing medical record integrity and data use
• Safeguard sensitive data by following established security policies and procedures, using systems responsibly, and promptly reporting potential security incidents, risks, or policy violations
• As applicable to your role, support cybersecurity and data protection requirements throughout the supplier lifecycle by coordinating vendor risk assessments, monitoring third-party compliance, and promptly reporting identified supply chain or cybersecurity risks

Additional Expectations:

• Demonstrate UHS Values of Compassion, Trust, Respect, Teamwork, and Innovation in all daily work and interactions
• Execute responsibilities in accordance with organizational policies, procedures, and applicable regulations
• Perform additional responsibilities as required to meet department and organizational needs

Position Qualifications

Required:

• High School Diploma or equivalent
• Any 1 of the following certifications:
• AHIMA Certified Documentation Integrity Practitioner (CDIP) or
• ACDIS Certified Clinical Documentation Specialist (CCDS) or
• AHIMA Certified Coding Specialist (CCS) or
• AAPC Certified Inpatient Coder (CIC)
• At least 7 years of direct experience performing the exact or very similar duties required by the job within the same role or function
• At least 7 years of experience in the same work environment or setting (hospital, practice, department/division)
• At least 7 years of healthcare experience working in the healthcare industry in any job function

Preferred:

• Associate Degree
• AHIMA Registered Health Information Administrator (RHIA) certification

Why You’ll Love Working at UHS

At United Health Services (UHS), we believe every connection—to patients, to purpose, to each other—makes a difference. That’s why we’re intentional about supporting our team in ways that go beyond the job. Whether through meaningful benefits, personal growth, or fun along the way, we’re here to help you thrive in work and life.

A Culture of Connection – We support each other like family and create space for every voice to be heard. Engagement Councils, peer recognition, and initiatives like Walk in my Shoes for senior leaders are just a few ways we foster belonging and collaboration. Outside of work, we stay connected through team events like trivia, trunk-or-treat, volunteer days, our staff choir, or seasonal celebrations.

Comprehensive Benefits for Life & Family – We offer medical, dental, and vision coverage starting the first of the month after hire for employees working 24+ hours/week. With flexible plan options and coverage tiers, you can choose what fits your life best. Additional perks include discounted childcare through Bright Horizons and voluntary benefits like pet insurance, legal services, and identity theft protection.

Well-Being & Financial Security – From day one, PTO starts accruing so you can take time to recharge. We support your long-term wellness with a 403(b) retirement plan and company match, flexible spending accounts, access to financial advisors, and up to $400/year in wellness rewards. When life gets tough, we’re here with 24/7 EAP counseling, virtual mental health support, a food pantry, PTO donation program, and professional attire through the Classy Closet.

Growth That Moves with You – With access to 100,000+ online courses, leadership programs, tuition reimbursement, clinical ladders, and internal mobility, we help you grow wherever your passion leads. We also continuously review compensation to ensure market competitiveness and internal equity, so you can feel confident your work is valued and rewarded fairly.

A Place to Call Home – Located in New York’s Southern Tier, UHS offers more than a career—we offer a lifestyle. Enjoy four-season recreation, affordable living, top-rated schools, minor league sports, craft brews, a close-knit community, and more, all within reach of the Finger Lakes, the Catskills, and major Northeast cities.

About United Health Services

United Health Services (UHS) is a locally owned, not-for-profit healthcare system in New York’s Southern Tier comprising four hospitals, long-term care and home care services, and physician practices in Broome and surrounding counties. UHS provides healthcare and medical services for two-thirds of the region’s population, produces $1.3 billion a year in total economic impact, and boasts a workforce of more than 6,300 employees and providers.

At UHS, our work is guided by our Values of Compassion, Trust, Respect, Teamwork, and Innovation. Whether you provide direct patient care or support behind the scenes, you are part of a shared purpose: to improve the health and well-being of the communities we serve. Every employee plays a meaningful role in fulfilling our mission—we’d love for you to consider joining us!

United Health Services is an Equal Opportunity Employer.

United Health Services, Inc. and the members of the UHS System neither are affiliated with, sponsored, endorsed nor approved by, nor otherwise associated with, Universal Health Services, Inc. (NYSE: UHS), UHS of Delaware, Inc. nor their affiliates.