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 [email protected] 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. Remote Skills: Acute Care, Analysis Skills, Case Management, Certified Case Manager (CCM), Clinical Medicine, Clinical Study Publications, Code Reviews, Communication Skills, Diagnosis-Related Group (DRG), Documentation, Electronic Medical Records, Emergency Nursing, Epic Systems, Healthcare, Hospital, Medical Coding, Medical Records, Medicare, Multitasking, Nursing, Nursing Credentials, Organizational Skills, Patient Care, People Management, Process Improvement, Quality Management, Quality Metrics, Registered Nurse (RN), Regulations, Regulatory Compliance, Reimbursement, Utilization Management, Validation Documentation About the Company: NavitasPartners