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Registered Nurse, Clinical Documentation Specialist
UVA Pipelines & PathwaysClinical Documentation Specialist ensuring accuracy in clinical documentation and collaborating with healthcare teams at UVA Health. Role is remote with flexible working hours and minimal patient interaction.
Posted 7/28/2026full-timeRemote • Virginia • 🇺🇸 United StatesMid-LevelSenior💰 $67,859 - $135,718 per yearWebsite
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in Clinical Documentation Improvement and evaluation of inpatient medical records, ensuring accuracy and compliance while collaborating with interdisciplinary teams. Proficient in managing caseloads and providing education to enhance documentation practices.
Highest-signal resume keywords
Clinical Documentation Specialist ExperienceRegistered Nurse LicenseCCDS CertificationICU Clinical ExperienceDocumentation Compliance
ATS Keywords
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Hard Skills
Clinical Documentation ImprovementMedical Record ReviewDocumentation Gap IdentificationPhysician Query IssuanceCoding SupportPatient Acuity EvaluationOutcome MeasurementEducation Provision
Soft Skills
Interdisciplinary CollaborationCommunication SkillsAttention to Detail
Certifications & Qualifications
CCDSCDIP
Industry Keywords
Inpatient RecordsDocumentation PracticesQuality TeamsHealthcare ComplianceVirginia Nursing License
About the role
Key responsibilities & impact- Leverage both your clinical background and CDI expertise to evaluate complex inpatient records and 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 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.
- Ensure 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 of 15 new cases per day, along with follow-ups and re-reviews.
Requirements
What you’ll need- RN, graduate of accredited nursing program and Bachelor of Science in Nursing required within 5 years of hire.
- 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.
- CCDS (Certified Clinical Documentation Specialist), or CDIP (Clinical Documentation Improvement Practitioner) is preferred.
- Licensed to Practice as a Registered Nurse in the Commonwealth of Virginia.
Benefits
Comp & perks- 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