Registered Nurse, Clinical Documentation Specialist

Job not on LinkedIn

🔥 0 minutes ago

⚔️ Virginia – Remote

⚔️ Virginia – Remote

💵 $67.9k - $135.7k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🏥📝 Medical Writer

Apply Now

Find Similar Remote Jobs

Set Up Email Alert For New Jobs

📊 Check your resume score for this job

Improve your chances of getting an interview by checking your resume score before you apply.

Upload Resume

UVA Pipelines & Pathways

WebsiteLinkedInAll Job Openings

10,000+ employees

📚 Education

🎯 Recruiter

Education • Recruitment

UVA Pipelines & Pathways is a University of Virginia careers program focused on helping job seekers access entry-level employment at UVA that does not require advanced education or prior work experience. The program aims to open doors into the university workforce and provide opportunities for upward mobility through targeted hiring pathways (including temporary and wage positions) and resources for applicants looking to join academic, administrative, and health-related roles within UVA.

📋 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 clinical information used to measure and report physician and hospital outcomes is accurate and complete • Provide education to providers to strengthen documentation practices • Manage a caseload of at least 15 new cases per day, including follow-ups and re-reviews • Work independently while collaborating with interdisciplinary teams without direct patient interaction

🎯 Requirements

• RN, graduate of an 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 • Licensed to practice as a Registered Nurse in the Commonwealth of Virginia • Strong acute care hospital experience, particularly in adult inpatient settings • Demonstrated Clinical Documentation Integrity (CDI) expertise • Ability to transition from bedside care to analytical review • Advanced critical thinking skills • Ability to work independently in a remote setting • Confidence engaging physicians and influencing documentation practices • Clinical experience in multiple areas, particularly in the ICU, preferred • Ability to work within a flexible 6:00 AM to 6:00 PM EST work window • Ability to manage at least 15 new cases per day, plus follow-ups and re-reviews • Occasional travel to attend meetings and programs

🏖️ 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 • Flexible scheduling • Part-time options • Continuous learning and professional growth opportunities