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Clinical Documentation Specialist

Westchester Medical Center

This is a Full-time position in Valhalla, NY posted April 29, 2021.

Job Title: Clinical Documentation Specialist (RN)

Company: Westchester Medical Center

Category: Nursing/Nursing Management

Department: Medical Records

Position: Full Time

Hours: 8 am to 4:30 pm

Shift: Day

Posted Date: Oct 20, 2020

Internal Posting – 10/20/20 to 11/9//20


Provides clinically based concurrent review of patient medical records to ensure documentation accurately reflects the level of clinical services, severity of illness and specificity of care. Responsibilities require interaction with physicians, nursing staff, medical records coding staff, compliance specialists and other healthcare providers to ensure that clinical information in the medical record is present and accurate so that the appropriate utilizations, clinical severity, outcomes and quality are captured for the level of service rendered and ensure compliant reimbursement of patient care services. Supervision may be exercised over a small support staff.Training and


Possession of a valid license and current registration issued by the New York State Education Department, as a Registered Nurse; current certification either by the ACDIS as a Certified Clinical Documentation Specialist (CCDS) or by AHIMA as a Certified Document Improvement Practitioner (CDIP) or Certified Coding Specialist (CCS);and either (1) three years experience where the primary function of the position was clinical documentation improvement or (2) five years professional nursing experience in a hospital or healthcare facility which included two years medical-surgical, intensive care or critical care experience.