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Lead Clinical Documentation Specialist
Company : BronxCare Health System
Location : Bronx, NY, 10457
Job Type : Full Time
Date Posted : 11 January 2026
Overview
The Clinical Documentation Specialist will work with Senior Director in physician education regarding documentation that meets severity of illness/intensity of service guidelines. The CDS will work with hospital top DRG’s to insure that documentation is optimal and meets coding clinic guidelines in order insure optimal hospital reimbursement. Prepares and presents reports pertinent to improvements and educational outcomes.
Responsibilities
- Assisting with the scheduling of staff to assure appropiate coverage.-
- Running and reviewing regular reports through several sourcees and utilizing information to: Analyze data and key metrics to find issues and develop a fix.
-Identify opportunities for CDS staff and physicians.
- Track technology issues with process tools and make requests to IT to improve upon them.
- Track query escalation process, CDS/Coder collaboration, etc. Coordinate with CDI Director.
- Identifies trends and opportunities for improvement in clinical documentation.
-Assist running weekly huddles or monthly meetings for CDI team and providing feedback to the CDI Director on operational concerns.
-Providing feedback to CDI Director on physician response issues.
-Work with the CDI Director to develop and oversee new hire training and orientation programs.
-Conduct audits of CDI queries and perform second level reviews.
- Identify DRG mismatches and manage and collaborate with Coding team on reconciling DRG mismatches.
-Develop montly educational topics for CDSs based on opportunities identified from second level reviews and query audits.
-Develop content and provide physician in-services as needed based on review if disagreed queries, ongoing opportunities, and physician process and outcome data.
Qualifications
-Registered nurse or other health care profession required.
-Three (3) years’ experience in a related position in Clinical or Health Information Management Department.
-Experience in ICD-9 and ICD-10, CPt-4 coding.
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Frequently asked questions
A Lead Clinical Documentation Specialist typically oversees complex documentation processes, mentors staff, and collaborates closely with physicians to optimize coding accuracy. This senior role demands advanced knowledge in ICD-10 coding, leadership in educational initiatives, and the ability to analyze data trends to enhance hospital reimbursement strategies.
Progression often requires mastering clinical coding systems like ICD-10 and CPT-4, strengthening data analysis capabilities, and gaining experience in staff coordination. Leadership skills and proficiency in developing educational content for physicians also significantly boost promotion prospects in this specialization.
Daily responsibilities often include auditing clinical records for accuracy, coordinating with coding teams to resolve discrepancies, running performance reports, and facilitating physician education sessions. In BronxCare Health System, specialists also engage in tracking query escalations and collaborating on technology tool improvements.
At BronxCare Health System, the Lead Clinical Documentation Specialist acts as a pivotal liaison between physicians and coders, ensuring documentation meets severity and coding guidelines. They support senior leadership by providing analytics-driven feedback and shaping educational programs that reinforce compliance and optimize reimbursement.
BronxCare emphasizes a healthcare professional background—often requiring registered nurse status—alongside hands-on experience with ICD-9, ICD-10, and CPT coding. Familiarity with hospital DRG systems and prior involvement in clinical documentation improvement initiatives are particularly valued in this institution.
Salaries in Bronx, NY for lead-level clinical documentation roles typically range between $85,000 and $105,000 annually, reflecting local cost of living and demand. This is generally competitive within New York State, with urban centers like Manhattan offering slightly higher pay but also higher expenses.
Bronx has seen a steady uptick in demand for clinical documentation experts due to regional healthcare expansion and regulatory emphasis on accurate coding. Candidates with strong ICD-10 expertise and leadership experience are increasingly sought after to meet evolving reimbursement and compliance standards.
Given Bronx's dense urban environment and reliance on public transit, many Clinical Documentation Specialists prefer shift structures that avoid peak travel hours. Flexible scheduling or hybrid work options can be advantageous, though onsite presence remains critical for collaboration with clinical teams.
BronxCare supports ongoing education through tailored training programs, monthly educational topics, and physician in-services designed by the clinical documentation leadership. These initiatives aim to sharpen coding accuracy, enhance query processes, and keep staff updated on evolving documentation guidelines.
While both roles focus on clinical data quality, the Lead Clinical Documentation Specialist at BronxCare assumes strategic oversight, including staff scheduling, advanced data analysis, and second-level query reviews. In contrast, a Coordinator often handles more administrative and operational support tasks without as much direct leadership or clinical audit involvement.