Remote Clinical Documentation Improvement RN

Role Overview

We are seeking a highly focused and experienced Remote Clinical Documentation Improvement (CDI) RN to join a team that values accuracy, excellence, and patient-centered care. This role ensures that healthcare documentation reflects the clinical picture and supports the quality of care provided. Operating fully remotely, you will review inpatient records and collaborate with providers to clarify documentation and ensure compliance with clinical, coding, and regulatory standards.

This is a critical opportunity for a detail-oriented, proactive nurse who thrives in a data-driven healthcare environment and understands the impact of documentation on both patient outcomes and institutional performance.

Annual Salary: $81,742

Key Responsibilities

Clinical Documentation Review

• Analyze inpatient records for completeness, consistency, and clarity.
• Identify gaps in documentation that impact coding, risk adjustment, and quality metrics.
• Provide timely feedback to providers to facilitate clarification of clinical documentation.
• Ensure documentation accurately captures the severity of illness, medical necessity, and care provided.

Provider Collaboration

• Communicate directly with physicians and advanced practice providers to obtain necessary clarifications.
• Educate providers on documentation best practices, regulatory compliance, and HCC or DRG considerations.
• Foster ongoing relationships that improve overall documentation quality.

Compliance & Quality Assurance

• Adhere to official coding guidelines, payer-specific requirements, and documentation integrity standards.
• Work within CDI software platforms and EMRs to monitor, track, and report activities.
• Participate in internal audits and continuous improvement efforts.

Reporting & Data Utilization

• Generate CDI metrics and contribute to performance dashboards.
• Identify trends in provider documentation patterns to inform future training.
• Collaborate with coding and quality assurance teams to align on institutional goals.

Work Environment

As a fully remote CDI RN, you will operate within a highly collaborative and results-driven environment. Your day-to-day will include:

• Digital collaboration with providers, coders, and quality teams.
• Regular check-ins via video or chat with the CDI department.
• Independent review of electronic health records (EHR) with robust tech support.
• Access to continuing education and best practice resources.

This remote structure enables you to maintain flexibility in your workday while driving clinical impact from anywhere.

Tools and Technology

You’ll leverage modern tools designed to enhance productivity and precision:

• EMR systems (e.g., Epic, Cerner)
• CDI platforms (e.g., 3M, Iodine, Optum360)
• Secure communication software (Microsoft Teams, Zoom)
• Cloud-based analytics dashboards
• Document workflow tracking tools

Training and support are provided to ensure you feel confident using all systems from day one.

Required Qualifications

• Active RN license in good standing (multi-state compact license preferred)
• Minimum of 3 years of bedside clinical experience in an acute care setting
• At least 2 years of experience in Clinical Documentation Improvement or Clinical Coding
• Solid understanding of disease pathology, coding standards (ICD-10), and MS-DRG or HCC models
• Proficiency in navigating EMRs and healthcare compliance platforms

Preferred Attributes

• CCDS or CDIP certification (preferred but not required)
• Prior experience in a remote nursing or CDI role
• Strong interpersonal skills and clinical judgment
• Ability to analyze large volumes of data quickly and make actionable decisions
• Self-discipline and comfort with independent work in a virtual setting

Benefits and Perks

We offer competitive benefits aligned with industry standards to support your well-being and professional growth:

• Flexible work hours and a 100% remote structure
• Comprehensive health, dental, and vision insurance
• Paid time off, holidays, and personal leave
• Reimbursement for certification and professional development
• Wellness programs and mental health support
• Access to virtual learning resources and mentorship

Growth Opportunities

As a Remote CDI RN, you’ll have the chance to grow beyond your current skill set:

• Participate in mentorship and leadership development tracks
• Contribute to nationwide clinical documentation standardization projects
• Lead provider education initiatives and pilot CDI innovations
• Collaborate with executive leadership on strategic clinical data goals

Why This Role Matters

Clinical documentation is more than recordkeeping—it reflects the full story of a patient’s care journey. As a CDI RN, your insights shape how care is measured, reimbursed, and improved. Your work supports transparency and quality improvement, ensuring that every patient interaction is fully recognized.

Ready to Make an Impact?

This is your opportunity to play a vital role in a modern healthcare landscape where precision and clinical truth matter more than ever. If you're detail-driven, tech-savvy, and passionate about high-quality patient records, we invite you to apply.

Your next impactful career move starts here. Apply now and bring clarity to care.