Registered Nurse – Case Management (Clinical Documentation) - RNCM25-24930

Job Title: Registered Nurse – Case Management (Clinical Documentation)
Location: Hyannis, MA (Hybrid)
Job Type: Contract
Pay Rate: $2625 weekly
Shift: Day Shift (7:00 AM – 3:30 PM)

Purpose of Position:

The Clinical Documentation Specialist (CDS) is responsible for reviewing medical records to ensure accurate representation of the patient’s severity of illness by improving the quality of clinical documentation. This supports appropriate DRG assignment, risk adjustment, reimbursement, and regulatory compliance.

Primary Duties and Responsibilities:

• Review medical records for documentation accuracy and completeness.

• Collaborate with physicians, HIM professionals, and nursing staff.

• Identify opportunities for documentation improvement and submit clinically appropriate queries.

• Ensure timely follow-up and resolution of documentation queries.

• Educate clinical staff on CDI processes and participate in team meetings.

• Input accurate data into the electronic medical record (EMR).

• Support CDI strategies and stay informed on Medicare Part A and B documentation impacts.

Qualifications:

• RN license in the state of Massachusetts (required).

• Graduate of an accredited nursing program; BSN preferred.

• 2–4 years of recent acute care experience (ICU, CCU, Med/Surg, or Case Management).

• Strong knowledge of pathophysiology, disease processes, and healthcare regulations.

• Proficient with Windows-based systems and EMRs.

• Excellent critical thinking, communication, and organizational skills.

• Prior leadership or supervisory experience is a plus.

Certifications:

• Certified Clinical Documentation Specialist (CCDS) – Preferred

• Clinical Documentation Improvement Practitioner (CDIP) – Preferred

• CDI Competency Exam – Preferred

• Certifications must be from ACDIS, AHIMA, or equivalent recognized body.