Lead Clinical Document Spec

As a community, the University of Rochester is defined by a deep commitment to Meliora - Ever Better. Embedded in that ideal are the values we share: equity, leadership, integrity, openness, respect, and accountability. Together, we will set the highest standards for how we treat each other to ensure our community is welcoming to all and is a place where all can thrive.

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Essential Functions:

• Directly participates in CDI assignments, serving as a clinical resource. Conducts complex medical record reviews to identify documentation improvement opportunities (e.g., for PSI, VBP, HAC, readmissions, PDX clarification). Develops effective physician queries. Monitors query rates and assists with project initiatives to enhance workflows and reporting outcomes.
• Supports and monitors staff workflows, productivity, and quality. Works with management to develop and monitor performance indicators related to the revenue cycle and quality outcomes. Maintains high customer service standards and assists with staff education on documentation, ICD-10, and IPPS updates. Participates in continuous professional development.
• Facilitates leadership support by giving input on daily operations, co-planning evaluations, modeling organizational behaviors (URMC/ICARE), and fostering trusting relationships. Recognizes staff, rounds for outcomes, provides timely feedback, assists with scheduling and accountability, facilitates staff meetings, participates in hospital committees, drives change, and onboards new team members.
• Contributes to broader hospital and departmental goals by participating in data collection, fostering interdisciplinary collaboration with various departments (e.g., physicians, Quality, HIM, Denials Management), ensuring adherence to regulatory guidelines and internal policies, and acting as a liaison to resolve documentation discrepancies. Represents CDI perspectives in interdisciplinary meetings and participates in hospital projects. Works collaboratively to analyze and report metrics to service lines. Leads processes improvement initiatives for documentation refinement.
• Other duties as assigned.

Minimum Education & Experience:

• Bachelor's degree in Nursing (BSN) and 6 years of inpatient clinical experience, knowledge of complex disease processes, including 2 years of Clinical Documentation Improvement expertise in acute care required OR
• Bachelor's, Master's or Doctorate degree in a relevant clinical discipline: Prepared Physician Assistant (PA) or Nurse Practitioner (NP) or Bachelor of Medicine, Bachelor of Surgery (MBBS) or Doctor of Medicine/Osteopathic Medicine (MD/DO) and 6 years inpatient clinical experience, knowledge of complex disease processes,  including 2 years of Clinical Documentation Improvement expertise in acute care required.
• Or equivalent combination of education and experience.
• Leadership experience preferred.

Knowledge, Skills & Abilities:

• Knowledge of hospital databases such as EPARC, eRecord, SharePoint, Iodine, 3M preferred.

Licenses and Certifications:

• Registered Nurse License, current in NYS upon hire required or NP – Nurse Practitioner license, current in NYS upon hire required or PA – Physician Assistant license current in NYS upon hire required or MD - Doctor of Medicine - MD License current in NYS upon hire required or DO - Doctor of Osteopathic Medicine current DO License in NYS upon hire required AND Clinical Documentation Specialist (CDS) upon hire required or CDIP - Clinical Documentation Improvement Professional upon hire required

The University of Rochester is committed to fostering, cultivating, and preserving an inclusive and welcoming culture to advance the University’s Mission to Learn, Discover, Heal, Create – and Make the World Ever Better. In support of our values and those of our society, the University is committed to not discriminating on the basis of age, color, disability, ethnicity, gender identity or expression, genetic information, marital status, military/veteran status, national origin, race, religion, creed, sex, sexual orientation, citizenship status, or any other characteristic protected by federal, state, or local law (Protected Characteristics). This commitment extends to non-discrimination in the administration of our policies, admissions, employment, access, and recruitment of candidates, for all persons consistent with our values and based on applicable law.