Job Title: Clinical Documentation Integrity (CDI) Specialist – Registered Nurse (RN)
Job Type: 13-Week Contract
Location: Remote (with optional on-site presence 1–2 days per week)
Shift: Rotating Days | 7:00 AM – 3:30 PM
Licensure Required: Massachusetts RN License, BLS Certification
Seeking an experienced and detail-oriented Clinical Documentation Integrity (CDI) Specialist to support accurate and complete clinical documentation in a healthcare setting. The ideal candidate will be a Registered Nurse with strong clinical and analytical skills, capable of working independently and collaboratively in a fast-paced environment.
Conduct timely and accurate medical record reviews to identify documentation improvement opportunities.
Communicate effectively with physicians to clarify and enhance documentation through clinically appropriate queries.
Identify gaps in documentation to reflect accurate patient acuity and clinical complexity.
Participate in team meetings, interdisciplinary case reviews, and staff education sessions.
Monitor and follow up on outstanding queries and documentation issues.
Collaborate with Health Information Management (HIM) staff to ensure coding and documentation alignment.
Maintain documentation metrics and ensure accurate data entry in the EMR system.
Apply knowledge of Medicare Part A and Part B in relation to DRG assignments and reimbursement models.
Provide professional service and maintain a respectful, cooperative demeanor with staff, patients, and families.
Balance multiple priorities effectively in a dynamic healthcare environment.
Support initiatives related to documentation strategy, compliance, and performance improvement.
Active and current Massachusetts Registered Nurse (RN) license.
Graduate of an accredited nursing program; BSN preferred.
CCDS certification or successful completion of a CDI Competency Exam is preferred or required.
Recent acute care clinical experience (preferably ICU, CCU, or strong Med/Surg background), or 4+ years of recent Case Management experience.
Strong understanding of pathophysiology, disease processes, and clinical standards of care.
Working knowledge of CMS guidelines, DRG methodologies, and regulatory requirements.
Excellent critical thinking, problem-solving, and communication skills.
Proficiency in EMR systems and Windows-based applications.
Previous leadership or supervisory experience is a plus.