Garnet Health

Clinical Documentation Specialist

Job Locations US-NY-Middletown
Job Post Information* : Posted Date 1 week ago(9/13/2021 11:36 AM)
Physical Location
Garnet Health Medical Center
Campus : Location
# of Openings
Business/Administrative Support/Clerical
Shift (1) : Shift Type
1 - Day
Shift (1) : If Other, Shift Slot
Days (7a-3p)


Garnet Health (formerly Greater Hudson Valley Health System,) is a New York State, not-for-profit corporation headquartered in Middletown, New York, approximately 60 miles north of New York City. Garnet Health is comprised of Garnet Health Medical Center, Garnet Health Medical Center - Catskills, Garnet Health Doctors, Garnet Health Foundation and Garnet Health Foundation - Catskills.  Garnet Health is dedicated to developing specialty services, medical programs and needed healthcare services that allow residents to remain close to home to receive quality care.

Providing healthcare to nearly 450,000 residents in Orange, Sullivan and Ulster Counties, Garnet Health was designed to improve the quality, stability and efficiency of healthcare services in the mid-Hudson and Catskill region. Services provided by more than 3,300 employed professionals and over 850 medical staff members, makes Garnet Health one of the largest healthcare providers in the tri-county area. The System’s three hospital campuses (Garnet Health Medical Center - Catskills (Harris and Callicoon, NY) and Garnet Health Medical Center (Middletown, NY) plus several outpatient facilities, offer a broad spectrum of care including:



The Clinical Documentation Specialist is responsible for improving the overall quality and completeness of clinical documentation within the inpatient record. Performs concurrent reviews, facilitates modifications to the clinical documentation to accurately reflect the severity of illness and risk of mortality through extensive interaction with physicians, coding and other health care professionals; serves as a resource to improve capture and accuracy of the final coded DRG; able to meet daily production expectations, while impacting on the integrity of the in-patient record. . Responsible for documentation accuracy, completeness and consistency in medical record from daily chart review.


Minimum Education:

  • Registered Nurse with current NYS license required
  • Bachelor's Degree in Nursing (BSN) required for all new hires beginning in 2021 and thereafter. 

Minimum Experience:

  • One (1) year experience working within CDI or Quality Services required.
  • Knowledge of coding principles, Medicare/Medicaid, thirty party payors, agency guidelines and payment methodologies required.
  • Experience with CDI programs required.
  • Knowledge of ICD-10 and DRG clinical documentation required.
  • Proficient with Microsoft Office Applications (Word, Excel, PowerPoint).
  • Highly developed verbal and written communication skills required.

Required Certification/Registration:

  • Clinical Documentation Specialist (CCDS) required within two years of hire.

Physical Requirements: Walking, standing, sitting, daily data entry.


Working Conditions:

  • Environmental Demands and Exposure to Hazards: Works in a clean, well-lighted, heated or ventilated facility. No routine exposure to hazards.
  • Physical Demands: Demonstrates physical and functional ability to perform full anatomical range of motion to accomplish tasks. Evidence of visual and aural acuity and finger and hand dexterity to operate computer and office equipment. Can withstand long periods of sitting, standing and/or constant walking. Ability to lift 10 lbs.
  • Mental Demands: Ability to foster collaborative relationships, to work well under pressure, to organize and synthesize new information, and prioritize tasks. Ability to communicate with a wide range of individuals and groups. Must have good organizational skills, judgment, safety awareness, problem solving, and time management skills.       Excellent interpersonal skills, including verbal and written communication. Possesses critical thinking, analytical skills and flexibility. Ability to multi-task, detailed attention to work in an environment where interruptions cannot be controlled. Demonstrates sensitivity to customer needs and expectations. May be subject to irregular hours including evenings or potentially weekends to participate in operational and community events as necessary.


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