Clinical Documentation Specialist- Registered Nurse

Clinical Documentation Specialist (CDS) - RN

OB/Newborn (OB/NB) CDI Training Program

Employment Type: Full-Time

Work Arrangement: Remote/Hybrid

Department: Clinical Documentation Integrity

Position Summary

We're seeking experienced Registered Nurses who are interested in transitioning from bedside care into a Clinical Documentation Integrity (CDI) career. Prior CDI experience is preferred but not required. Selected candidates will receive comprehensive training in CDI fundamentals and OB/Newborn documentation.

Key Responsibilities

• Review inpatient medical records for completeness, accuracy, and clinical consistency.
• Identify documentation improvement opportunities and issue compliant provider queries.
• Collaborate with physicians, coding, HIM, case management, and other healthcare teams.
• Support accurate clinical documentation reflecting severity of illness, quality outcomes, and medical necessity.
• Maintain case follow-up, productivity standards, and CDI compliance requirements.
• Participate in training, audits, education initiatives, and process improvement activities.

Required Qualifications

• Active, unrestricted RN license.
• Minimum 5 years of acute-care hospital nursing experience
• Background in Labor & Delivery, Mother-Baby, NICU, Women's Services, ICU, ED, Med-Surg, or other acute-care specialties.
• Strong clinical assessment, critical thinking, communication, and documentation skills.
• Comfortable working independently in a remote or hybrid environment.

Preferred Qualifications

• Prior CDI/CDS experience.
• OB, Women's Services, Labor & Delivery, Mother-Baby, or NICU experience.
• BSN preferred.
• CCDS, CDIP, or related CDI certifications are a plus.
• Experience with Epic, Cerner, 3M, Optum, Iodine, Nuance, or similar platforms.

Training & Development

• CDI fundamentals and documentation improvement principles
• Provider query best practices
• Coding and DRG basics
• OB/Newborn clinical documentation and review processes
• Case-based learning and supervised chart reviews