Clinical Documentation Specialist- Registered Nurse

Safeguard Global; Philippines; Hybrid; PHP 400,000 - 700,000; Full time

Job summary

Safeguard Global is seeking an experienced Registered Nurse to transition into a Clinical Documentation Integrity role as a CDS - RN. This full-time position offers a Remote/Hybrid work arrangement and belongs to the Clinical Documentation Integrity department.

Training will cover CDI fundamentals, OB/Newborn documentation, and ongoing chart reviews. The ideal candidate has at least 5 years of acute-care nursing, active RN license, and strong assessment and documentation skills.

Qualifications

• Active RN license required.
• Minimum 5 years of acute-care hospital nursing experience.
• Preference for CDI/CDS experience and OB/Delivery/NICU backgrounds.

Responsibilities

• Review inpatient medical records for completeness and accuracy.
• Identify documentation improvement opportunities and issue provider queries.
• Collaborate with physicians, coding, HIM, and case management teams.

Skills

Clinical assessment

Critical thinking

Communication

Documentation

Independent work

Education

BSN degree

CDDS/CDIP certifications

RN license active

Tools

Epic

Cerner

3M

Optum

Iodine

Nuance

Job description

Clinical Documentation Specialist (CDS) - RN

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
• Coding and DRG basics
• OB/Newborn clinical documentation and review processes
• Case-based learning and supervised chart reviews