The Judge Group

Clinical Documentation Specialist Nurse (RN or LPN)

Posted on

May 30, 2025

Job Type

Contract

Role Type

Clinical Operations

License

RN

State License

Pennsylvania

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Company Description

Job Description

Job Title: Clinical Documentation Integrity RN or LPN (Remote) Job Type: W2 contract to hire/ temp to perm (conversion to full time after 6 months) Location: Remote (U.S. Based) Schedule: Monday to Friday, 8:00 AM–4:30 PM EST (Training start between 8–9 AM EST) Job Summary: We are seeking a highly skilled and coachable Clinical Documentation Integrity (CDI) RN or LPN to join our team. This role focuses on improving the accuracy and quality of clinical documentation through concurrent and retrospective reviews of medical records. The ideal candidate has strong DRG knowledge, is query-proficient, and brings 2–5+ years of recent adult bedside CDI experience.

Requirements

Minimum Requirements License: Active RN or LPN/LVN licensure (NPs also considered) Certification Required: CCDS (Certified Clinical Documentation Specialist) through ACDIS Verify at: acdis.org Not Accepted: CDIP certification Optional: CRCR (Certified Revenue Cycle Representative) through HFMA Verify at: hfma.org Experience: 2–5+ years of CDI experience in adult bedside settings (5 years preferred) DRG assignment and query development proficiency required Experience with MS-DRG and APR-DRG focused reviews strongly preferred Skills & Abilities: Proficiency in querying and clinical code assignment Solid understanding of healthcare reimbursement models and documentation compliance Exceptional written/verbal communication and interpersonal skills Strong public speaking and training skills Ability to lead cross-functional collaboration and education initiatives Adaptable, highly coachable, and a proactive team contributor Proficient in Microsoft Office Suite and EMR systems Additional Information: A pre-submission assessment mirroring the CCDS exam will be required (provided by R1 upon conditional approval) Candidates must demonstrate a track record of teamwork and adaptability in high-performance environments How to Apply: Submit your resume along with your CCDS certification and licensing details. Qualified candidates will be contacted to complete the required assessment.

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Responsibilities

Conduct clinical documentation reviews to ensure accurate severity of illness, risk of mortality, and complexity of care. Initiate and formulate provider queries when documentation is unclear or incomplete. Lead education efforts for providers and CDI teams based on audit trends and findings. Evaluate CDI team accuracy and standardize review findings and reporting. Collaborate with HIMS, Coding, and Quality teams for complete documentation and accurate DRG assignment. Maintain expert knowledge in CDI best practices, regulatory compliance, and coding guidelines (MS-DRG, APR-DRG). Participate in special reviews such as mortality, PSI, and other quality-driven documentation assessments.

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