Clinical expertise meets analytical precision in a role that directly shapes how patient care is captured, understood, and valued across the health system. As a Clinical Documentation Specialist, you bring a seasoned nursing perspective into a high-impact environment where your insight ensures the integrity, accuracy, and completeness of the clinical story.
This fully remote opportunity is ideal for experienced registered nurses with at least three years of recent clinical practice, a strong acute care background, and demonstrated expertise in Clinical Documentation Integrity (CDI). Designed for nurses ready to transition from direct patient care into a more analytical and collaborative role, this position offers the opportunity to leverage your clinical knowledge to improve documentation quality, support interdisciplinary teams, and drive positive patient outcomes. If you enjoy critical thinking, problem-solving, and continuous professional growth, this role offers a rewarding next step in your nursing career.
The RoleIn this role, you will leverage both your clinical background and CDI expertise to evaluate complex inpatient records and ensure documentation accurately reflects patient acuity and care delivery. This is a highly collaborative yet independent position, requiring strong clinical judgment without direct patient interaction.
This role operates within a
flexible 6:00 AM to 6:00 PM EST work window, allowing autonomy in structuring your day while maintaining strong collaboration with the broader team.
You will be most successful in this role if you bring:
- Strong acute care hospital experience, particularly in adult inpatient settings, along with experience working as a Clinical Documentation Specialist
- The ability to transition from bedside care to analytical review, applying clinical judgment in a non-direct care environment
- Advanced critical thinking skills and comfort working independently in a remote setting
- Confidence engaging physicians and influencing documentation practices
On a typical day, you will:
- 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 interdisciplinary teams, including:
- Physicians and advanced practice providers
- Coding professionals
- Quality teams and service lines
- Specialty teams such as wound care and nutrition
- Support accurate coding prior to discharge
- Ensures the accuracy and completeness of clinical information, which is used for measuring and reporting physician and hospital outcomes
- Provide education to providers to strengthen documentation practices
- Manage a steady caseload >/= 15 new cases per day, along with follow-ups and re-reviews
MINIMUM REQUIREMENTS
Education: RN, graduate of accredited nursing program and Bachelor of Science in Nursing required within 5 years of hire.
Experience: A minimum of three years of experience as a Clinical Documentation Specialist is required. Clinical experience in multiple areas, particularly in the ICU, is preferred.
Licensure: Licensed to Practice as a Registered Nurse in the Commonwealth of Virginia.
PHYSICAL DEMANDS
This is primarily a sedentary job involving extensive use of desktop computers. The job does occasionally require traveling some distance to attend meetings, and programs.
The pay range for this role is $67,859.00 - $135,718.00 annually. Individual compensation will be determined by the selected candidate's qualifications, previous work experience, and/or education.
Benefits- Comprehensive Benefits Package: Medical, Dental, and Vision Insurance
- Paid Time Off, Long-term and Short-term Disability, Retirement Savings
- Health Saving Plans, and Flexible Spending Accounts
- Certification and education support
- Generous Paid Time Off
UVA Health is a world-class Magnet Recognized academic medical center and health system with a level 1 trauma center. 2023-2024 U.S. News & World Report "Best Hospitals" guide rates UVA Health University Medical Center as "High Performing" in 5 adult specialties and 14 conditions/procedures. We are one of 70 National Cancer Institute designated cancer centers. UVA Health Children's is named by 2023-2024 U.S. News & World Report as the best children's hospital in Virginia with 9 specialties ranked among the best in the nation. Our footprint also encompasses 3 community hospitals and an integrated network of primary and specialty care clinics throughout Charlottesville, Culpeper, Northern Virginia, and beyond.
