Remote Registered Nurse – Clinical Documentation Specialist

About the role

The Clinical Documentation Specialist (CDS) works remotely to improve the quality and completeness of clinical documentation across the health system. The RN will partner with physicians, nursing staff, and coding teams to ensure accurate documentation that supports appropriate reimbursement and outcome reporting.

Key responsibilities

• Perform admission and continued‑stay reviews using CDMP guidelines to enhance documentation quality.
• Facilitate modifications to clinical records so severity of illness is accurately captured for DRG‑based payers (Medicare, Blue Cross, etc.).
• Conduct follow‑up reviews to confirm clarification points are recorded.
• Educate physicians, nurses, and other caregivers on documentation best practices.
• Collaborate with coding staff to align documentation with coding requirements and reimbursement goals.

Required profile

• Current RN licensure in Georgia.
• Associate degree (minimum) with five years of professional nursing experience, preferably in critical care or medical‑surgical settings.
• Strong analytical, observation, and problem‑solving abilities.
• Self‑directed with solid computer skills and ability to work remotely under a formal agreement.

Required skills

• DRG coding optimization strategies.
• ICD‑10 coding conventions.
• Medical terminology and anatomy/physiology knowledge.
• MS‑DRG reimbursement concepts.
• Experience with coding software, preferably 3M 360 Encompass.