Clinical Documentation Specialist Full Time

Job Summary:

We are seeking a detail-oriented Registered Nurse (RN) with experience in Clinical Documentation Improvement (CDI) to support concurrent and retrospective chart reviews. The ideal candidate will have hands-on experience with Iodine/APR methodologies and familiarity with Epic (preferred).

Key Responsibilities:

• Perform concurrent and post-discharge reviews of patient records
• Identify documentation gaps and opportunities for physician queries prior to coding
• Ensure accuracy and completeness of clinical documentation
• Review 6–10 cases per day while maintaining a target query rate of 30%
• Utilize tools such as Epic and 3M 360 for documentation review and workflow management
• Collaborate with clinical and coding teams to improve documentation quality

Requirements:

• Active RN license
• CDI experience with concurrent reviews
• CCDS required
• Proficiency in Epic (preferred) and 3M 360
• Strong analytical and communication skills