Registered Nurse – Clinical Documentation Specialist

This is a fully remote position, open to applicants in Virginia.

📋 Description

• Assess intricate inpatient records to guarantee that documentation accurately represents patient acuity and the care provided.

• Examine inpatient medical records for precision, completeness, and adherence to compliance standards.

• Detect documentation deficiencies, inconsistencies, and areas that require clarification.

• Generate physician queries to address ambiguous or incomplete documentation.

• Collaborate with physicians, advanced practice providers, coding professionals, quality teams, service lines, wound care, nutrition, and specialty teams.

• Facilitate accurate coding prior to patient discharge.

• Ensure the precision and completeness of clinical information utilized for evaluating and reporting physician and hospital outcomes.

• Educate providers to enhance documentation practices.

• Oversee daily caseloads, follow-ups, and re-reviews.

• Operate both collaboratively and independently without direct patient interaction.

⛳️ Requirements

• Registered Nurse (RN) with a degree from an accredited nursing program.

• Bachelor of Science in Nursing is required within five years of hire.

• A minimum of three years of experience as a Clinical Documentation Specialist.

• Strong experience in acute care hospitals, especially in adult inpatient settings.

• Proven expertise in Clinical Documentation Integrity (CDI).

• Capability to transition from bedside care to analytical review in a non-direct care setting.

• Advanced critical thinking abilities.

• Ability to work independently in a remote environment.

• Confidence in engaging with physicians and influencing documentation practices.

• Licensed to practice as a Registered Nurse in the Commonwealth of Virginia.

• Availability to work within the 6:00 AM to 6:00 PM EST time frame.

• Manage a caseload of at least 15 new cases each day.

🏝️ Benefits

• Medical, Dental, and Vision Insurance.

• Paid Time Off.

• Long-term and Short-term Disability benefits.

• Retirement Savings options.

• Health Saving Plans.

• Flexible Spending Accounts.

• Support for certification and education.

• Generous Paid Time Off.

• Fully remote work with flexible scheduling options.

• Availability of part-time positions.

• Opportunities for continuous learning and professional development.