Role Description The Clinical Documentation Specialist (CDS) reviews medical records to ensure accurate clinical documentation that reflects patient severity of illness, supports quality outcomes, and optimizes reimbursement. The role collaborates closely with physicians, HIM professionals, and clinical staff to improve documentation quality and compliance.

• Conduct comprehensive and timely medical record reviews.
• Identify documentation improvement opportunities and issue clinically supported queries.
• Collaborate with physicians, nursing staff, and HIM teams to resolve documentation discrepancies.
• Maintain accurate data entry within the electronic medical record (EMR).
• Follow up on outstanding queries and documentation issues.
• Participate in CDI team meetings, task forces, and staff education initiatives.
• Support clinical documentation strategies and regulatory compliance.
• Manage multiple priorities while maintaining high-quality standards.
• Provide excellent customer service and professional communication.

Qualifications

• Current Massachusetts RN license required.
• Graduate of an accredited nursing program; BSN preferred.
• Certified Clinical Documentation Specialist (CCDS) or CDI Competency Exam required.
• Recent acute care experience required, preferably ICU, CCU, or strong Medical/Surgical background; OR 4 years of recent Case Management experience (within the last 4 years).
• Strong knowledge of pathophysiology, disease processes, Medicare Part A & B guidelines, DRG assignment, and regulatory requirements.
• Epic EMR experience required.
• Prior fully remote work experience required.
• Excellent analytical, critical thinking, communication, organizational, and problem-solving skills.
• Management or supervisory experience preferred.

Preferred Skills

• Strong physician communication and query-writing abilities.
• Ability to work independently in a remote environment.
• Proficiency with Windows-based applications and electronic medical records.

Contact Information For more details reach at [email protected] or Call / Text at 516-862-1203.

Company Description

Navitas Healthcare, LLC 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.