*RN, Clinical Documentation Specialist

1. Extensive record review, interaction with physicians, HIM professionals, and nursing staff.
2. Active participation in team meetings and education of staff in the  CDI process is a key role.
3. Ability to learn/develop the skills necessary to perform CDI duties. 
4. Accurate and timely record review.
5. Recognize opportunities for documentation improvement.
6. Formulate clinically credible queries.
7. Effective and appropriate communication with physicians.
8. Timely follow up on all cases especially those with queries.
9. Participate in Task Force meetings.
10. Manage multiple priorities.
11. Communicates with HIM staff and resolves discrepancies.
12. Accurate input of data into   the electronic medical record.
13. Understand and support clinical documentation strategies.
14. Consistently provides service excellence to all patients, family members, visitors, volunteers and co-workers.
15. Understand and communicate differences between Medicare Part A and Part B guidelines and how they impact DRG assignments.

RN, Clinical Documentation Specialist – Grade: NSI4, Job Code: 3057

• Graduate of a School of Nursing
• (RN) - Currently licensed as a Registered Nurse in the Commonwealth of Massachusetts
• (BSN) – A Bachelor of Science in Nursing (external applicants only)
• Minimum of 3 years of current RN, CDI Practice experience
• Must meet at least one of the following qualifications:
  1. Certified Clinical Documentation Specialist (CDI)
  2. CCHC Clinical Documentation Specialist Exam
• Knowledge of Medicare Part A and Part B  
• Knowledge of regulatory environment
• Organizational, analytical, writing and interpersonal skills
• Dependable and self-directed
• Critical thinking, problem solving and deductive reasoning skills
• Knowledge of pathophysiology and disease process
• Basic computer skills – familiarity with Windows based software programs
• Strong interpersonal and negotiation skills demonstrated by a positive attitude, pleasant, professional and cooperative demeanor with physicians, fellow employees & all customers 

*!%3Cp style=%22margin: 0in;;text-align:left%22 style=%22margin-top:0px;margin-bottom:0px%22%3E%3Cstrong style=%22font-size: 16pt;%22%3E%3Cbr /%3E%0A%3C/strong%3E%3C/p%3E%0A%3Cp style=%22margin: 0in;;text-align:left%22 style=%22margin-top:0px;margin-bottom:0px%22%3E%3Cstrong style=%22font-size: 16pt;%22%3EPay Range Details%3C/strong%3E%3C/p%3E%0A%3Cp style=%22margin: 0in;;text-align:left%22 style=%22margin-top:0px;margin-bottom:0px%22%3E%3Cstrong%3EThe%26nbsp;pay%26nbsp;range displayed on each job posting reflects the anticipated range for new hires. A successful candidate’s actual compensation will be determined after taking factors into consideration such as the candidate’s work history, experience, skill set, and education. This is not inclusive of the value of Cape Cod Healthcare’s benefits package (if applicable), which includes among other benefits, healthcare/dental/vision and retirement. For annual salaries this is based on full-time employment.%3C/strong%3E%3C/p%3E%0A%3Cp style=%22margin: 0in;;text-align:left%22 style=%22margin-top:0px;margin-bottom:0px%22%3E%3Cbr /%3E%0A%3C/p%3E%0A%3Cp class=%22MsoNormal%22 style=%22margin-top: 0px; margin-bottom: 0px;;text-align:left%22%3E%3Cstrong style=%22font-size: 16pt;%22%3EBeware scam interview requests%3C/strong%3E%3C/p%3E%0A%3Cp class=%22MsoNormal%22 style=%22margin-top: 0px; margin-bottom: 0px;;text-align:left%22%3E%3Cstrong%3ECape Cod Healthcare has been made aware of an instance in which a potential scammer has attempted to impersonate CCHC leadership and request chat interviews. Please note this is not our process and we will never direct you to interview solely through web-based chat. For any questions about available job opportunities or to learn more about our interview process please visit our careers page:%26nbsp;%3Ca href=%22https://www.capecodhealth.org/careers/%22%3E%3Cspan style=%22line-height: 107%;%22%3E%3Cspan style=%22font-family:%26quot;microsoft sans serif%26quot;, sans-serif%22%3E%3Cspan style=%22font-size:11.5pt%22%3Ehttps://www.capecodhealth.org/careers/%3C/span%3E%3C/span%3E%3C/span%3E%3C/a%3E%3C/strong%3E%3C/p%3E

Job Details
Purpose of Position: The CDS is responsible for reviewing medical records to facilitate the accurate representation of the severity of illness by improving the quality of the physicians’ clinical documentation.
Schedule Details: 40 Hours Per Week, Mon-Fri, Rotating Days, 7a-3:30p, Rotating Weekends and Rotating Holidays
Organization: Cape Cod Hospital
Primary Location: Hyannis
Department: CCH-Care Management
Job Grade: MN2
Hours Per Pay Period: 32
Pay Frequency: weekly
Annual/Hourly: Hourly
$: 42.04
$: 89.99
Posting Start Date: Aug 4, 2026
Posting End Date: Aug 11, 2026