Registered Nurse – Clinical Documentation Specialist

🔥 0 minutes ago

⚔️ Virginia – Remote

⚔️ Virginia – Remote

💵 $67.9k - $135.7k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🏥📝 Medical Writer

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UVA Health

WebsiteLinkedInAll Job Openings

10,000+ employees

🏥 Healthcare

📚 Education

🔬 Science

💰 $100k Grant - UVA Health on 2025-01

Healthcare • Education • Science

UVA Health is an integrated academic health system aligned with the University of Virginia that combines clinical care, education, and research. It comprises the flagship University Medical Center (a 600‑bed academic medical center in Charlottesville with a Level I trauma center, Level IV NICU, and an NCI‑designated Comprehensive Cancer Center), the UVA School of Medicine and School of Nursing, UVA Physicians Group, a top-ranked children’s hospital, three community hospitals, a specialty rehabilitation hospital, and an integrated network of primary and specialty care clinics across Virginia. UVA Health operates both tertiary/academic and community care sites and supports medical education, training programs, and clinical research.

📋 Description

• Evaluate complex inpatient records to ensure documentation accurately reflects patient acuity and care delivery • Review inpatient medical records for accuracy, completeness, and compliance • Identify documentation gaps, inconsistencies, and opportunities for clarification • Issue physician queries to resolve unclear or incomplete documentation • Partner with physicians, advanced practice providers, coding professionals, quality teams, service lines, wound care, nutrition, and specialty teams • Support accurate coding prior to discharge • Ensure the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes • Provide education to providers to strengthen documentation practices • Manage daily caseloads, follow-ups, and re-reviews • Work collaboratively and independently without direct patient interaction

🎯 Requirements

• Registered Nurse (RN), graduate of accredited nursing program • Bachelor of Science in Nursing required within 5 years of hire • Minimum of three years of experience as a Clinical Documentation Specialist • Strong acute care hospital experience, particularly in adult inpatient settings • Demonstrated expertise in Clinical Documentation Integrity (CDI) • Ability to transition from bedside care to analytical review in a non-direct care environment • Advanced critical thinking skills • Ability to work independently in a remote setting • Confidence engaging physicians and influencing documentation practices • Licensed to Practice as a Registered Nurse in the Commonwealth of Virginia • Ability to work within the 6:00 AM to 6:00 PM EST work window • Manage a caseload of at least 15 new cases per day

🏖️ Benefits

• Medical, Dental, and Vision Insurance • Paid Time Off • Long-term and Short-term Disability • Retirement Savings • Health Saving Plans • Flexible Spending Accounts • Certification and education support • Generous Paid Time Off • Fully remote work with flexible scheduling • Part-time options • Continuous learning and professional growth opportunities