Job Title: RN Clinical Documentation Specialist (Remote)
Job Category: Remote | Nursing | Clinical Documentation Integrity (CDI)
Job Summary:
We are seeking an experienced and detail-oriented Clinical Documentation Specialist (CDS) to join our remote healthcare team. This role requires a licensed RN with expertise in acute care and clinical documentation. The ideal candidate will perform comprehensive Clinical Documentation Integrity (CDI) reviews across all patient populations, ensuring accuracy, completeness, and compliance with current coding and reimbursement guidelines. This position plays a vital role in improving quality outcomes, ensuring accurate reimbursement, and supporting enterprise-wide documentation goals.
Key Responsibilities:
- Conduct detailed chart reviews and data collection using CDI software systems.
- Apply advanced clinical knowledge and critical thinking to identify documentation improvement opportunities aligned with organizational goals.
- Collaborate with physicians, mid-level providers, nursing staff, and coding professionals to clarify documentation, support accurate coding, and ensure appropriate reimbursement.
- Perform initial, follow-up, and reconciliation CDI reviews following ACDIS and AHIMA best practices.
- Train and provide guidance to Associate CDS nurses to support department growth and performance.
- Analyze and address complex clinical documentation and coding issues, including procedural coding and DRG-specific trends.
- Ensure accurate recording of points of clarification in the patient’s medical record.
- Maintain comprehensive records supporting DRG, Case Mix Index (CMI), and quality performance metrics.
- Stay current on coding guidelines, DRG regulations, payer trends, and quality reporting requirements.
- Assist in other duties as assigned by leadership.
Required Skills & Experience:
- Minimum 5 years of acute care nursing experience.
- At least 1 year of hospital-based CDI experience.
- Proficiency with Microsoft Office Suite (Excel, Outlook, Word), WebEx, and Epic or similar EMR systems.
- Strong communication, negotiation, and presentation skills.
- Ability to analyze and interpret complex clinical data and treatment plans.
- Comfortable interacting across multidisciplinary teams and all levels of the organization.
- Knowledge of MSDRG/APRDRG, DRG/CMI impact, and coding best practices.
- Capable of maintaining accurate and clear process documentation.
- Strong time management and follow-through from project initiation to completion.
Job Type: Contract
Pay: $57.00 per hour
Schedule:
- Day shift
- Monday to Friday
Work Location: Remote
