Remote CDI RN – New Jersey

Position Summary

The Clinical Documentation Improvement (CDI) Registered Nurse is responsible for reviewing inpatient medical records to ensure accurate, complete, and compliant clinical documentation that reflects the patient’s severity of illness, risk of mortality, and quality of care provided. This fully remote role collaborates closely with physicians, coding professionals, and quality teams to support accurate reimbursement, regulatory compliance, and data integrity.

Key Responsibilities

• Conduct concurrent and/or retrospective reviews of inpatient medical records to identify documentation gaps, inconsistencies, or opportunities for clarification
• Initiate and manage compliant physician queries to improve specificity and accuracy of diagnoses and procedures
• Ensure documentation supports appropriate DRG assignment, severity of illness (SOI), risk of mortality (ROM), and quality metrics
• Collaborate with coding, case management, utilization review, and quality teams to promote accurate clinical representation
• Educate providers on documentation best practices, coding guidelines, and regulatory requirements
• Apply current CMS, ICD-10-CM/PCS, MS-DRG, and payer-specific guidelines in daily review activities
• Maintain productivity and quality benchmarks while working independently in a remote environment
• Participate in CDI team meetings, audits, and ongoing performance improvement initiatives

Qualifications

• Active, unrestricted Registered Nurse (RN) license
• Minimum of 3-5 years of recent acute care clinical experience (ICU, ED, or medical-surgical preferred)
• At least 2 years of Clinical Documentation Improvement experience required
• Strong knowledge of pathophysiology, disease processes, and clinical indicators
• Solid understanding of ICD-10 coding principles, DRG methodology, and regulatory guidelines
• Excellent written and verbal communication skills, particularly for physician engagement
• Ability to work independently, manage time effectively, and meet productivity standards in a remote setting

Preferred Credentials

• CCDS (Certified Clinical Documentation Specialist) or CDIP certification
• Experience with CDI software platforms and electronic health records
• Prior remote CDI work experience

Work Environment

• Fully remote / work-from-home position
• Standard business hours; minimal to no weekends or holidays
• Requires secure home workspace and reliable internet connection

For California Applicants:

We will consider for employment all qualified Applicants, including those with criminal histories, in a manner consistent with the requirements of applicable federal, state and local laws, including the City of Los Angeles’ Fair Chance Initiative for Hiring Ordinance (FCIHO), Los Angeles Fair Chance Ordinance for Employers (ULAC), The San Francisco Fair Chance Ordinance (FCO) , and the California Fair Chance Act (CFCA).

This position is subject to a background check based on its job duties, which may include patient care, working with vulnerable populations, access to financial and confidential information, driving, working with heavy machinery, or working in a warehouse or laboratory environment. Due to these job duties, this position has a significant impact on the business operations and reputation, as well as the safety and well-being of individuals who may be cared for as part of the job position or who may interact with staff or clients.