RN Clinical Documentation Specialist

We are seeking an experienced Registered Nurse – Clinical Documentation Specialist (CDS) for a remote opportunity supporting clinical documentation improvement initiatives. The CDS will collaborate with physicians, coding teams, quality departments, and clinical leadership to ensure accurate, complete, and compliant medical documentation that reflects the severity of illness and quality of patient care. The ideal candidate will possess strong critical thinking skills, clinical expertise, and current CDI experience in an acute care setting.

Key Responsibilities

• Review inpatient medical records to ensure accurate and complete clinical documentation
• Collaborate with physicians and interdisciplinary teams to clarify documentation and improve record accuracy
• Support clinical documentation improvement (CDI) initiatives to enhance coding quality, reimbursement, and compliance
• Serve as a liaison between clinical staff, coding teams, health information management, and quality departments
• Identify opportunities for documentation enhancement related to severity of illness and risk adjustment
• Utilize EPIC CDI and Solventum end coder software for documentation review and workflow management
• Ensure compliance with regulatory guidelines and documentation standards
• Participate in clinical competency evaluations and ongoing education initiatives
• Maintain effective communication with physicians, coders, and leadership teams regarding documentation opportunities

Qualifications

• Active RN License (New Jersey or Compact License required at time of submission)
• Minimum 5 years of nursing experience with current Clinical Documentation Specialist (CDS/CDI) experience required
• Must have hands-on experience with EPIC CDI, Solventum end coder software, and Critical Care nursing
• CCDS Certification preferred
• Must successfully pass a Clinical Competency Exam conducted via Zoom prior to interview
• Strong knowledge of anatomy, physiology, pathophysiology, and pharmacology
• Preferred acute care background in Med Surg, Critical Care, Emergency Department, or PACU settings
• Must have an active BLS certification from AHA
• Excellent communication, analytical, critical thinking, and collaboration skills
• Ability to work independently and efficiently in a remote work environment while maintaining productivity and accuracy

Important Details:

• 8-week contract position (extensions available)
• Shift is Day 5x8-Hour (08:00 AM - 04:30 PM), 40 hrs/week
• Fully remote role
• Pay Range for Locals: $58 - $62 per hour

Call to Action:

• Spots Are Filling Quickly — Apply Now!

Company Description:

“Pride Health offers eligible employee’s comprehensive healthcare coverage (medical, dental, and vision plans), supplemental coverage (accident insurance, critical illness insurance and hospital indemnity), 401(k)-retirement savings, life & disability insurance, an employee assistance program, legal support, auto, home insurance, pet insurance, and employee discounts with preferred vendors”

Equal Employment Opportunity

Pride Health is an equal opportunity employer. We do not discriminate on the basis of the race, religious creed, color, national origin, ancestry, physical disability, mental disability, reproductive health decision making, medical condition, genetic information, marital status, sex, gender, gender identity, gender expression, age, sexual orientation, veteran or military status, or any other characteristic protected by applicable federal, state, or local law.

Fair Chance Employment

Pride Health is a Fair Chance employer. We consider all qualified applicants, including those with criminal histories, in a manner consistent with applicable state and local Fair Chance laws and ordinances, including, the California Fair Chance Act and all applicable local Fair Chance ordinances.

Accommodations

We are committed to providing reasonable accommodations to applicants and employees with disabilities. If you require a reasonable accommodation to participate in the application or interview process, or to perform the essential functions of this role, please contact us.