TN Visa Clinical Documentation Specialist Jobs
Clinical Documentation Specialists qualify for TN visa sponsorship under the USMCA's Medical/Health Information Technologist category, making this one of the more straightforward paths for Canadian and Mexican professionals. Your RHIA, RHIT, or CCS credential does the heavy lifting with U.S. employers, and Canadian citizens can enter at the port of entry without pre-filing.
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Get Access To All JobsEmployment 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 TN Visa Clinical Documentation Specialist Jobs
Sign up for free to unlock all listings, filter by visa type, and get alerts for new TN Visa Clinical Documentation Specialist Jobs.
Get Access To All JobsTips for Finding TN Visa Sponsorship as a Clinical Documentation Specialist
Align your credentials to U.S. HIM standards
AHIMA credentials like RHIA or RHIT are the benchmarks U.S. employers use to evaluate foreign applicants. If your Canadian or Mexican certification doesn't map cleanly, a credential equivalency letter from AHIMA strengthens your TN visa sponsorship case before you apply.
Target health systems with in-house CDI teams
Large hospital networks and integrated health systems maintain dedicated CDI departments and handle TN sponsorship internally. Smaller clinics often lack HR infrastructure for it, so filtering your search to multi-facility employers saves time and avoids dead ends.
Distinguish remote roles from fully remote offers carefully
TN status requires employment with a U.S. employer, but CDI roles are frequently remote. Confirm the employer is a U.S.-registered entity and that your offer letter specifies a U.S. worksite address, even if your day-to-day work is remote, to avoid CBP complications at the border.
Use Migrate Mate to find experienced visa-sponsoring employers
Searching generically wastes time on employers unfamiliar with visa sponsorship processes. Migrate Mate surfaces Clinical Documentation Specialist roles at employers with recent visa filings, so you're only contacting companies already experienced with sponsoring work visas.
Get your offer letter to match USMCA occupation language
CBP officers check that your job title and duties align with the Medical/Health Information Technologist category. Ask your employer to use that exact USMCA language in the offer letter rather than generic HR titles like 'documentation coordinator,' which can trigger questions at the border.
Prepare for Mexican nationals' annual cap limitations
Mexico's TN allocation is capped at 5,500 per year across all eligible occupations. Apply early in the fiscal year and confirm with USCIS that the category remains open, since approval timelines for Mexican nationals can compress when the cap approaches.
Clinical Documentation Specialist TN Visa: Frequently Asked Questions
Does a Clinical Documentation Specialist qualify for TN visa sponsorship?
Yes. Clinical Documentation Specialists qualify under the USMCA's Medical/Health Information Technologist category, which covers professionals who manage clinical records, coding, and health data integrity. You'll need a qualifying credential such as an RHIA, RHIT, or CCS, or a relevant bachelor's degree in health information management to satisfy CBP's documentation requirements at the port of entry or during USCIS adjudication.
How does TN visa sponsorship compare to H-1B for this role?
TN is significantly more practical for Clinical Documentation Specialists than H-1B visa. There's no annual lottery, no cap for Canadian citizens, and Canadians can be approved at the border the same day with a qualifying offer letter. H-1B requires a spring lottery and months of waiting with no guarantee of selection. For a role that fits cleanly into an existing USMCA category, TN is the faster and more predictable path.
Where can I find Clinical Documentation Specialist jobs that sponsor TN visas?
Most general job boards don't filter by visa sponsorship type, which means you'll spend time applying to employers who won't sponsor or don't know how. Migrate Mate is built specifically for TN visa job seekers and surfaces Clinical Documentation Specialist roles from employers with active sponsorship capacity, saving you the guesswork of cold applications.
Can I work remotely in Canada or Mexico on a TN visa as a Clinical Documentation Specialist?
No. TN status requires you to physically work in the United States for a U.S.-based employer. CDI roles are often listed as remote, but remote in this context means working from a U.S. location, not from your home country. Working from Canada or Mexico while on TN status violates the terms of your authorization and could jeopardize future U.S. entry.
What happens to my TN status if my employer switches to a different health system or gets acquired?
An employer change or acquisition typically requires a new TN authorization because TN status is tied to the specific employer named in your approval. Canadian citizens can request a new TN at the border with an updated offer letter from the acquiring entity. Mexican nationals need to file a new USCIS petition. Start this process before your last day with the original employer to avoid a gap in work authorization.