Weekend/Holiday Requirement: Rotating weekends and occasional holidays
Position Summary
We are seeking an experienced Registered Nurse (RN) Clinical Documentation Specialist to support clinical documentation improvement (CDI) initiatives in a fully remote environment. This role is responsible for reviewing patient medical records to ensure accurate and complete clinical documentation, reflecting severity of illness and appropriate reimbursement.
The ideal candidate will have strong clinical knowledge, experience with electronic medical records, and the ability to collaborate effectively with physicians and interdisciplinary teams.
Key Responsibilities
Conduct thorough and timely reviews of medical records to ensure accurate clinical documentation
Identify opportunities for documentation improvement and initiate appropriate queries
Communicate effectively with physicians and clinical staff to clarify documentation
Collaborate with Health Information Management (HIM) and nursing teams to resolve discrepancies
Ensure accurate data entry and maintenance within the electronic medical record system
Participate in CDI initiatives, team meetings, and ongoing education efforts
Provide follow-up on documentation queries to ensure timely resolution
Support compliance with regulatory requirements and documentation standards
Maintain high standards of service excellence when interacting with internal stakeholders
Manage multiple priorities in a fast-paced, remote work environment
Required Qualifications
Current Registered Nurse (RN) license in Massachusetts
Certified Clinical Documentation Specialist (CCDS) or CDI certification required
Prior experience working fully remotely
Experience with Epic Electronic Medical Records system
Minimum of recent acute care experience (ICU, CCU, or strong Med/Surg) OR 4 years of recent Case Management experience
Strong knowledge of pathophysiology and disease processes
Understanding of Medicare Part A & B guidelines and DRG impact
Familiarity with regulatory healthcare requirements
Strong analytical, critical thinking, and problem-solving skills
Excellent written and verbal communication skills
Ability to work independently and manage multiple tasks effectively
Preferred Qualifications
Bachelor of Science in Nursing (BSN)
Previous leadership or supervisory experience
Experience in Clinical Documentation Improvement programs
Key Competencies
Strong organizational and time management skills
High attention to detail and accuracy
Effective interpersonal and negotiation skills
Self-motivated and dependable with a proactive approach
Ability to collaborate with cross-functional teams in a remote setting
Work Environment
Fully remote role with structured daytime schedule
Requires a dedicated workspace and ability to work independently
Equipment and system access will be provided as per organizational policy
For more details reach at Aditi.sharma@navitashealth.com or Call / Text at 516-587-6677.
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.