Location
New York, New York
Shift:
Day (United States of America)
Description:
Documentation Improvement Specialist - HYBRID (4 days in Queens office)
The Documentation Improvement Specialist is responsible for facilitating improvement of medical record documentation by concurrent and retrospective interventions and interactions with, as well as the provision of education to physicians, residents, and other licensed independent practitioners. Develops process to identify opportunities for documentation improvement, intervene with attending physicians, residents, and physician extenders, in order to facilitate improvement in medical record documentation. Provides routine in-services to assigned clinical areas/Service Lines regarding regulatory documentation requirements including feedback on the impact of clinician documentation on Service Line metrics. Initiates and maintains records and databases to quantify the deficits, the interventions, and their impact. Conducts successful interventions related to documentation improvement and ensures follow through with all recommendations. Identifies, investigates, and evaluates practices and processes to facilitate continuous improvement in complete and accurate medical record documentation.
Participates in retrospective medical record reviews to collect data and/or to resolve coding or documentation discrepancies. Maintains knowledge of coding, billing and documentation guidelines related to the therapists’ clinical professions and third party payer requirements. Collaborates with Manager of Coding Unit as needed. In collaboration with Coding Unit expertise, provides in-services to educate therapy staff and clinicians on the following but not limited to: correct billing, coding and documentation through clear verbal and/or written communication. Performs other job related duties as assigned.
This is full time day(8:00 am - 4:00 pm) position. You will be expected to be in office 4-5 days a week.
Required Criteria
Bachelor's degree
Registered Nurse, Nurse Practitioner, Occupational Therapist, Physical Therapist, Physician Assistant or trained Physician background
5 years of recent hospital experience and/or verifiable Documentation Improvement experience
Experience in an Electronic Medical Record (EMR)environment
Preferred Criteria
Registered Nurse with 2 years of CDI experience
Bachelor’s Degree in Nursing
Current Registered Nurse, Nurse Practitioner or Physician Assistant license highly preferred
Join a healthcare system where employee engagement is at an all-time high. Here we foster a culture of respect, belonging, and inclusion. Enjoy comprehensive and competitive benefits that support you and your family in every aspect of life. Start your life-changing journey today.
Please note that all roles require on-site presence (variable by role). Therefore, all employees should live within a commutable distance to NYP.
NYP will not reimburse for travel expenses.
2026 Best Companies in Healthcare, Biotech & Pharma – Glassdoor
2026 Best Place to Work – Glassdoor
2026 America’s Best Large Employers – Forbes
2026 America’s Best-In-State Employers – Forbes
2026 America’s Dream Employers – Forbes
2026 America’s Greatest Workplaces for Culture, Belonging & Community – Newsweek
2026 Best Places to Work in IT - Computerworld
2025 Great Place to Work Certified
2025 Best Employers for Women – Forbes
2025 Companies that Care – People
2025 America’s Greatest Workplaces for Mental Well-Being - Newsweek
NewYork-Presbyterian Hospital is an equal opportunity employer.
Salary Range:
$101,000-$151,000/Annual
It all begins with you. Our amazing compensation packages start with competitive base pay and include recognition for your experience, education, and licensure. Then we add our amazing benefits, countless opportunities for personal and professional growth and a dynamic environment that embraces every person. Join our team and discover where amazing works.
Documentation Improvement Specialist - HYBRID (4 days in Queens office)The Documentation Improvement Specialist is responsible for facilitating improvement of medical record documentation by concurrent and retrospective interventions and interactions with, as well as the provision of education to physicians, residents, and other licensed independent practitioners. Develops process to identify opportunities for documentation improvement, intervene with attending physicians, residents, and physician extenders, in order to facilitate improvement in medical record documentation. Provides routine in-services to assigned clinical areas/ Service Lines regarding regulatory documentation requirements including feedback on the impact of clinician documentation on Service Line metrics. Initiates and maintains records and databases to quantify the deficits, the interventions, and their impact. Conducts successful interventions related to documentation improvement and ensures follow through with all recommendations. Identifies, investigates, and evaluates practices and processes to facilitate continuous improvement in complete and accurate medical record documentation. Participates in retrospective medical record reviews to collect data and/or to resolve coding or documentation discrepancies. Maintains knowledge of coding, billing and documentation guidelines related to the therapists’ clinical professions and third party payer requirements. Collaborates with Manager of Coding Unit as needed. In collaboration with Coding Unit expertise, provides in-services to educate therapy staff and clinicians on the following but not limited to: correct billing, coding and documentation through clear verbal and/or written communication. Performs other job related duties as assigned. This is full time day(8:00 am - 4:00 pm) position. You will be expected to be in office 4-5 days a week. Required Criteria Bachelor's degree. Registered Nurse, Nurse Practitioner, Occupational Therapist, Physical Therapist, Physician Assistant or trained Physician background 5 years of recent hospital experience and/or verifiable Documentation Improvement experience. Experience in an Electronic Medical Record (EMR)environment. Preferred Criteria Registered Nurse with 2 years of CDI experience Bachelor’s Degree in Nursing. Current Registered Nurse, Nurse Practitioner or Physician Assistant license highly preferred. Join a healthcare system where employee engagement is at an all-time high. Here we foster a culture of respect, belonging, and inclusion. Enjoy comprehensive and competitive benefits that support you and your family in every aspect of life. Start your life-changing journey today. Please note that all roles require on-site presence (variable by role). Therefore, all employees should live within a commutable distance to NYP. NYP will not reimburse for travel expenses .026 Best Companies in Healthcare, Biotech & Pharma – Glassdoor 2026 Best Place to Work – Glassdoor 2026 America’s Best Large Employers – Forbes 2026 America’s Best-In-State Employers – Forbes 2026 America’s Dream Employers – Forbes 2026 America’s Greatest Workplaces for Culture, Belonging & Community – Newsweek 2026 Best Places to Work in IT - Computerworld 2025 Great Place to Work Certified 2025 Best Employers for Women – Forbes 2025 Companies that Care – People 2025 America’s Greatest Workplaces for Mental Well-Being - Newsweek. New. York-Presbyterian Hospital is an equal opportunity employer. Salary Range:$101,000-$151,000/ Annual. It all begins with you. Our amazing compensation packages start with competitive base pay and include recognition for your experience, education, and licensure. Then we add our amazing benefits, countless opportunities for personal and professional growth and a dynamic environment that embraces every person. Join our team and discover where amazing works.
search terms: Improvement Specialist+Registered Nurse