Clinical Documentation Improvement Specialist, RN

Job Description

Location: Remote

We are seeking a Clinical Documentation Improvement Specialist, RN to strengthen the accuracy, specificity, and clinical integrity of inpatient documentation through concurrent review and compliant physician collaboration. This position is a full-time, contract to hire opportunity based remotely, supporting a Texas based health system. The role partners closely with physicians, advanced practice providers, and coding teams to ensure the medical record fully reflects each patient’s clinical picture.

This role is well aligned for an experienced CDI nurse who brings strong acute care clinical judgment and views documentation improvement as a clinical partnership. The ideal candidate writes clear, compliant, non-leading queries, builds productive working relationships with providers, and educates with confidence across service lines.

Responsibilities:

• Perform concurrent review of inpatient records for documentation specificity and clinical validity
• Identify opportunities to clarify diagnoses, severity, and present on admission status
• Write compliant, non-leading physician queries consistent with ACDIS and AHIMA practice briefs
• Follow queries through to response and track physician response and agreement rates
• Validate that documented conditions are supported by clinical indicators in the record
• Assess working DRG accuracy and identify opportunities related to severity of illness and risk of mortality
• Collaborate with coding on DRG reconciliation and resolve documentation variances
• Educate physicians and advanced practice providers on documentation requirements by service line
• Support denial prevention through strong clinical validity documentation at the point of care
• Track CDI metrics, including review coverage, query rate, response rate, and case mix impact
• Participate in clinical validation denial appeals with supporting record evidence
• Maintain current knowledge of coding guidelines and payer clinical validation criteria

Qualifications:

• Bachelor of Science in Nursing preferred
• Active, unrestricted Texas or compact Registered Nurse license required
• CCDS or CDIP certification strongly preferred
• Minimum of 3 years of clinical documentation improvement experience
• Demonstrated experience writing compliant physician queries
• Working knowledge of MS-DRG and APR-DRG methodology, severity of illness, and risk of mortality
• Strong acute care clinical background, with critical care or medical-surgical experience preferred
• Familiarity with clinical validation denials and appeal support

Schedule:

• Full-time, contract to hire position with conversion anticipated after the initial contract period
• Remote position
• Monday through Friday, standard business hours ([Time Zone])
• 40 hours per week

Salary Range: The salary range for this position is approximately $88,000 – $108,000 annually ($42.31 – $51.92 per hour), based on experience and qualifications.

Interview Process: Selected candidates will participate in a multi-step interview process, including an initial screening with TalentLNX followed by interviews with department leadership.

Equal Opportunity Employer: TalentLNX is committed to equal employment opportunity and a diverse, inclusive workforce. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status.