Clinical Documentation Specialist (CDS), RN – Remote | Contract - RNAP

Clinical Documentation Specialist (CDS), RN – Remote | Contract

Location: Hyannis, MA (Remote)

Duration: 13 Weeks

Shift: Day Shift

Responsibilities:

• Conduct comprehensive reviews of inpatient medical records.

• Evaluate documentation for accuracy, completeness, specificity, and clinical validity.

• Identify opportunities for documentation improvement and clarification.

• Develop and issue compliant physician queries.

• Collaborate with physicians to improve documentation quality and coding accuracy.

• Work closely with HIM, coding, case management, and nursing teams.

• Follow up on outstanding queries and documentation opportunities.

• Maintain CDI documentation and activities within Epic EMR.

• Participate in CDI meetings, educational initiatives, and process improvement projects.

• Support documentation integrity, quality metrics, reimbursement, and regulatory compliance efforts.

• Apply Medicare Part A and Part B guidelines related to documentation and DRG assignment.

• Manage multiple priorities while maintaining productivity and quality standards.

• Serve as a clinical documentation resource for interdisciplinary teams.

Preferred:

• Bachelor of Science in Nursing (BSN).

• Previous CDI experience in an acute care setting.

• Management or supervisory experience.

• Advanced knowledge of coding guidelines, DRG validation, and documentation regulations.

• Experience collaborating with coding, utilization review, and case management teams.

Requirements:

• Active Massachusetts Registered Nurse (RN) License.

• Graduate of an accredited nursing program.

• CCDS Certification or successful completion of a CDI Competency Exam.

• Hands-on Epic EMR experience.

• Prior fully remote work experience.

• Strong knowledge of Clinical Documentation Improvement (CDI) principles.

• Knowledge of DRG assignment methodologies and reimbursement processes.

• Knowledge of Medicare Part A and Part B regulations.

• Understanding of healthcare regulatory and compliance requirements.

• Strong analytical, organizational, critical-thinking, and communication skills.

• Ability to work independently in a remote environment.

Clinical Experience Requirement (One of the Following):

• Recent Acute Care Nursing experience in ICU, CCU, or Medical-Surgical settings.
  OR

• Minimum 4 years of recent Case Management experience within the last 4 years.

For more details contact at hdavda@navitashealth.com or Call / Text at 516-862-1169.

About Navitas Healthcare, LLC:
It is a Joint Commission Certified / WBENC and one of the fastest-growing healthcare staffing firms in the US providing Medical, Clinical and Non-Clinical services to numerous hospitals. We offer the most competitive pay for every position we cater. We understand this is a partnership. You will not be blindsided and your salary will be discussed upfront.