This position will be a 6-9 month set contract to support automation within the business office. Contract needs may extend longer. 100% remote role.
Description
We need an RN who has 2-3 years working as a Clinical Documentation Integrity RN in the acute care inpatient setting with experience in the adult patient population.
They need to have experience collaborating with other clinicians, coding staff, and CDI leaders on medical records/charting to help improve data integrity.
Epic experience is also required.
The Clinical Documentation Specialist (CDS) is responsible for performing concurrent review of medical records to ensure complete and accurate clinical documentation to support severity of illness, risk of mortality for outcomes reporting, and for hospital reimbursement.
The position requires a strong attention to detail and process orientation and an ability to think globally about documentation requirements in the medical records.
The CDS must communicate effectively in oral and written form to physicians and other clinicians to promote accurate and complete documentation during the patient’s course of care.
CDS supports the hospital’s overall compliance efforts designed to ensure the accuracy of diagnosis and procedural coding, Diagnosis Related Group (DRG) assignment, severity of illness (SOI), and expected risk of mortality (ROM).
This role uses Nuance CDE One as their clinical documentation integrity (CDI) software system. This position is a highly demanding and not a relaxed work from home opportunity! Please make sure consultants are locked down on the demanding expectations of this role - this role has a direct financial impact to Unity Point.
Daily Duties
Conducts reviews of designated medical records to facilitate the creation of a health record that accurately represents the acuity of the patient’s illness and the resources used to treat the patient by ensuring provider documentation supports all applicable diagnosis codes.
Ensures assignment of the working DRG is supported by diagnostic and procedural findings from the medical record. This will include the identification of secondary diagnosis that may result in Complications and Co-morbidities (CC) and/or Major Complications and Co-morbidities (MCC) assignment.
Utilizes a compliant query process per guidelines and policies and follows each query through closure including complete documentation of ongoing follow up and communication.
Maintains integrity and compliance of medical record reviews, clinical documentation integrity documentation, and queries.
Meets the minimum productivity and quality assurance standards established by the CDI department.
Collaborates with coding staff and leaders for improved knowledge and understanding of coding guidelines.
Collaborates with physicians and/or other hospital staff to coordinate work and resolve issues.
Top Skills Details RN, CDI
Qualifications
Registered Nurse Certification
Clinical Documentation Integrity RN experience in an adult acute care setting - 3-5 years
Experience collaborating with other clinicians, coding staff, and CDI leaders on medical records/charting to help improve data integrity
Epic experience is also required.
Work from home space required
Prefer
BSN or higher certification
Previous experience in clinical documentation improvement
Previous experience with chart review or chart auditing
Nuance CDE One experience
Knowledge of ICD CM/PCS coding guidelines
Certified Clinical Documentation Specialist (CCDS)
Job Type & Location This is a Contract position based out of Chicago, IL.
Pay And Benefits The pay range for this position is $35.00 - $41.00/hr.
Eligibility requirements apply to some benefits and may depend on your job classification and length of employment. Benefits are subject to change and may be subject to specific elections, plan, or program terms. If eligible, the benefits available for this temporary role may include the following:
Medical, dental & vision
Critical Illness, Accident, and Hospital
401(k) Retirement Plan – Pre‑tax and Roth post‑tax contributions available
Life Insurance (Voluntary Life & AD&D for the employee and dependents)
Short and long‑term disability
Health Spending Account (HSA)
Transportation benefits
Employee Assistance Program
Time Off/Leave (PTO, Vacation or Sick Leave)
This is a fully remote position. Application Deadline: This position is anticipated to close on Feb 20, 2026.
The company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.
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Description
We need an RN who has 2-3 years working as a Clinical Documentation Integrity RN in the acute care inpatient setting with experience in the adult patient population.
They need to have experience collaborating with other clinicians, coding staff, and CDI leaders on medical records/charting to help improve data integrity.
Epic experience is also required.
The Clinical Documentation Specialist (CDS) is responsible for performing concurrent review of medical records to ensure complete and accurate clinical documentation to support severity of illness, risk of mortality for outcomes reporting, and for hospital reimbursement.
The position requires a strong attention to detail and process orientation and an ability to think globally about documentation requirements in the medical records.
The CDS must communicate effectively in oral and written form to physicians and other clinicians to promote accurate and complete documentation during the patient’s course of care.
CDS supports the hospital’s overall compliance efforts designed to ensure the accuracy of diagnosis and procedural coding, Diagnosis Related Group (DRG) assignment, severity of illness (SOI), and expected risk of mortality (ROM).
This role uses Nuance CDE One as their clinical documentation integrity (CDI) software system. This position is a highly demanding and not a relaxed work from home opportunity! Please make sure consultants are locked down on the demanding expectations of this role - this role has a direct financial impact to Unity Point.
Daily Duties
Conducts reviews of designated medical records to facilitate the creation of a health record that accurately represents the acuity of the patient’s illness and the resources used to treat the patient by ensuring provider documentation supports all applicable diagnosis codes.
Ensures assignment of the working DRG is supported by diagnostic and procedural findings from the medical record. This will include the identification of secondary diagnosis that may result in Complications and Co-morbidities (CC) and/or Major Complications and Co-morbidities (MCC) assignment.
Utilizes a compliant query process per guidelines and policies and follows each query through closure including complete documentation of ongoing follow up and communication.
Maintains integrity and compliance of medical record reviews, clinical documentation integrity documentation, and queries.
Meets the minimum productivity and quality assurance standards established by the CDI department.
Collaborates with coding staff and leaders for improved knowledge and understanding of coding guidelines.
Collaborates with physicians and/or other hospital staff to coordinate work and resolve issues.
Top Skills Details RN, CDI
Qualifications
Registered Nurse Certification
Clinical Documentation Integrity RN experience in an adult acute care setting - 3-5 years
Experience collaborating with other clinicians, coding staff, and CDI leaders on medical records/charting to help improve data integrity
Epic experience is also required.
Work from home space required
Prefer
BSN or higher certification
Previous experience in clinical documentation improvement
Previous experience with chart review or chart auditing
Nuance CDE One experience
Knowledge of ICD CM/PCS coding guidelines
Certified Clinical Documentation Specialist (CCDS)
Job Type & Location This is a Contract position based out of Chicago, IL.
Pay And Benefits The pay range for this position is $35.00 - $41.00/hr.
Eligibility requirements apply to some benefits and may depend on your job classification and length of employment. Benefits are subject to change and may be subject to specific elections, plan, or program terms. If eligible, the benefits available for this temporary role may include the following:
Medical, dental & vision
Critical Illness, Accident, and Hospital
401(k) Retirement Plan – Pre‑tax and Roth post‑tax contributions available
Life Insurance (Voluntary Life & AD&D for the employee and dependents)
Short and long‑term disability
Health Spending Account (HSA)
Transportation benefits
Employee Assistance Program
Time Off/Leave (PTO, Vacation or Sick Leave)
This is a fully remote position. Application Deadline: This position is anticipated to close on Feb 20, 2026.
The company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.
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