Job Title: RN – Case Management / Clinical Documentation Specialist (Remote) Location: Remote (Based out of Massachusetts) Schedule: Day Shift | 32 Hours per Week Shift Timing: 7:00 AM – 3:30 PM 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 [email protected] 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.