Registered Nurse; RN; Clinical Documentation Specialist; Remote

Registered Nurse (RN) - Clinical Documentation Specialist (Remote)

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.

In 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

Why UVA Health UVA Health offers the best of academic medicine, clinical excellence, and a culture grounded in collaboration and continuous improvement. This role is central to ensuring that the complexity and quality of care delivered across the system is accurately represented and understood. What sets this opportunity apart:

• A Strategic, High-Impact Role Directly influences clinical quality metrics and documentation integrity, making your work essential to both patient care and organizational success
• Fully Remote with Flexible Structure Work within a true remote model with the flexibility to manage your schedule while maintaining strong team connectivity
• Ideal Transition from Bedside Nursing Apply your clinical expertise in a role that emphasizes critical thinking, analysis, and collaboration over physical demands
• Collaborative, Physician-Facing Work Engage meaningfully with providers and interdisciplinary teams, serving as a trusted clinical documentation partner
• Commitment to Professional Growth Thrive in an environment that values continuous learning, especially in a field shaped by evolving clinical and regulatory standards
• Balanced, Sustainable Workload Predictable case volumes and flexible scheduling support strong work-life integration, including part-time options

Why People Love Living in Charlottesville Charlottesville offers a unique blend of professional opportunity and exceptional quality of life. Surrounded by the Blue Ridge Mountains, the area provides year-round access to outdoor recreation, from hiking and cycling to vineyards and scenic escapes. The city itself is known for its vibrant food scene, rich history, and strong sense of community. For healthcare professionals, Charlottesville delivers a balanced lifestyle where a meaningful career at UVA Health can coexist with personal well-being, family life, and cultural enrichment.

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…