Clinical Documentation Integrity Specialist – Registered Nurse - CDIRN 25-24930

Santa Barbara Cottage Hospital; United States; Remote; USD 70,000 - 90,000; Full time

Job summary

A leading healthcare provider is seeking a Clinical Documentation Integrity (CDI) Specialist to support accurate clinical documentation. This role requires an experienced RN with excellent analytical skills, able to work in a fast-paced environment while ensuring documentation meets compliance and performance standards.

Qualifications

• Active Massachusetts RN license required.
• Recent acute care clinical experience preferred.
• CCDS certification preferred or completion of CDI Competency Exam.

Responsibilities

• Conduct timely medical record reviews to identify documentation improvement opportunities.
• Clarify documentation with physicians through clinically appropriate queries.
• Collaborate with Health Information Management staff to ensure alignment.

Skills

Critical thinking

Problem-solving

Communication

Education

Graduate of an accredited nursing program; BSN preferred

Tools

EMR systems

Windows-based applications

Job description

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

Job Summary:

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.

Key Responsibilities:

• 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.

Qualifications:

• 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.