Job openings
Clinical Documentation Specialist (CDS) – RN
OB / Newborn (NB) CDI Training Program
Employment Type: Full-Time | Work Arrangement: Remote/Hybrid | Department: Clinical Documentation Integrity
Position Summary
We are seeking an experienced Registered Nurse with a strong acute-care clinical background to join our Clinical Documentation Integrity (CDI) team. The ideal candidate will bring strong clinical judgment, medical terminology, chart-review skills, and the ability to communicate effectively with physicians and multidisciplinary teams. Prior CDI experience is preferred but not required; candidates with the right clinical foundation will receive structured training in CDI principles and specialized Obstetrics and Newborn (OB/NB) documentation.
This role is designed for experienced RNs who are ready to transition from bedside practice into a clinical documentation-focused career while developing expertise in OB and newborn documentation.
Key Responsibilities
• Conduct concurrent review of inpatient medical records to assess completeness, accuracy, specificity, and clinical consistency.
• Identify documentation opportunities by comparing clinical indicators, diagnoses, treatments, procedures, and patient acuity with provider documentation.
• Develop and issue compliant physician/provider queries when clarification or greater specificity is clinically supported.
• Collaborate with physicians, advanced practice providers, nursing, coding, HIM, quality, case management, and other members of the healthcare team.
• Support accurate representation of severity of illness, risk of mortality, quality outcomes, medical necessity, and complexity of care.
• Review OB and newborn cases after completion of training, applying organization-specific CDI workflows, guidelines, and escalation processes.
• Maintain timely follow-up on open cases and documentation queries.
• Participate in CDI education, quality initiatives, audits, process improvement, and team meetings.
• Maintain working knowledge of ICD-10-CM/PCS concepts, MS-DRG/APR-DRG methodology as applicable, and CDI/query compliance standards.
• Use EHR and CDI technology effectively and maintain accurate case documentation and productivity metrics.
OB / Newborn Specialty Focus
Following core CDI training, the selected RN will receive focused training in OB/NB documentation and case review. Specialty education may include:
• Pregnancy, labor, delivery, postpartum, and newborn clinical documentation
• Maternal and fetal complications and conditions affecting pregnancy
• Cesarean and vaginal delivery documentation, including clinically relevant complications
• Hypertensive disorders of pregnancy, diabetes in pregnancy, hemorrhage, infection, anemia, and other high-impact conditions
• Preterm birth, respiratory conditions, birth weight/gestational age, neonatal complications, and NICU-related documentation
• Clinical indicators and documentation specificity relevant to maternal and newborn populations
• Provider query opportunities and compliant query construction in OB/NB cases
Required Qualifications
• Active, unrestricted Registered Nurse (RN) license.
• Minimum 3 years of recent acute-care hospital nursing experience; 5+ years preferred.
• Strong candidates may come from Labor & Delivery, Mother-Baby/Postpartum, NICU, Women's Services, Med-Surg, ICU, ED, or another acute-care specialty.
• Strong clinical assessment, critical-thinking, chart-review, and written/verbal communication skills.
• Comfort working independently with high attention to detail and meeting productivity/time-sensitive review requirements.
• Proficiency with electronic medical records and standard computer applications.
Preferred Qualifications
• Prior Clinical Documentation Integrity (CDI/CDS) experience.
• Prior experience in OB, Labor & Delivery, Mother-Baby, Women's Services, NICU, or neonatal care.
• BSN preferred.
• CCDS, CDIP, or other CDI credential preferred, but not required for candidates entering the training program.
• Experience with Epic, Cerner, 3M, Optum, Iodine, Nuance, or similar EHR/CDI platforms.
Training & Development
Candidates selected for this role will complete a structured onboarding program covering foundational CDI methodology, clinical documentation principles, compliant provider queries, coding/DRG fundamentals, workflow expectations, and OB/NB specialty concepts. Training will combine classroom/online education, case-based learning, supervised chart review, feedback, and progressive case ownership.
The goal is to develop clinically strong RNs into independent OB/NB CDI specialists rather than requiring prior CDI experience at hire.
Core Competencies
• Clinical judgment and critical thinking
• Attention to detail and analytical ability
• Professional physician/provider communication
• Strong written communication
• Ability to interpret complex medical records
• Knowledge of anatomy, physiology, pathophysiology, and clinical treatment
• Ability to learn coding and CDI concepts
• Time management, organization, and independent work
• Commitment to compliant, ethical documentation practices
Why This Role
This position offers experienced acute-care nurses an opportunity to leverage their clinical expertise outside traditional bedside nursing while building a specialized career in Clinical Documentation Integrity. Successful candidates will receive the training and support needed to develop expertise in CDI and the OB/Newborn service line.