Clinical Documentation Improvement Specialist
Summary
A remote Clinical Documentation Improvement Specialist reviews medical records to ensure accuracy and compliance, collaborates with healthcare teams, and improves clinical documentation for better patient outcomes and reimbursement.
Join a Team That’s Elevating CDI Excellence!
At UASI, we're driven by a mission to improve the quality and accuracy of clinical documentation through expert CDI consulting. As we continue to grow our service offerings, we’re looking for experienced and motivated Clinical Documentation Improvement (CDI) professionals to join our dedicated team in a fully remote capacity.
This role is critical to supporting the accuracy of coded data, compliance with regulatory requirements, and improving the quality of clinical outcomes reporting. The ideal candidate will have a clinical background, excellent analytical skills, and a passion for ensuring accurate and compliant clinical documentation.
Key Responsibilities
- Review and evaluate medical record documentation for completeness, accuracy, and compliance.
- Collaborate with physicians, nurses, and coding professionals to ensure appropriate clinical documentation.
- Identify opportunities for documentation improvement to support coding accuracy, reimbursement, and clinical outcomes.
- Analyze medical records to ensure documentation supports quality care and appropriate reimbursement.
- Formulate compliant, clinically sound physician queries.
Qualifications:
- Minimum of 2 years of inpatient clinical documentation improvement (CDI) experience
- Minimum of 2 years of bedside nursing experience in an acute care setting (ICU, Med/Sure, ED, Etc.)
- Utilization of 3M and Epic software preferred (but not required)
- Certification: Registered Nurse (RN) required and CCDS/CDIP preferred but not required
- Knowledge of ICD-10-CM, MS-DRGs, coding guidelines, and compliance standards.
- Excellent communication, critical thinking, and organizational skills.
- Comfortable using MS Office, email, VPNs, virtual machines, two-factor authentication, and video conferencing tools (MS Teams, Zoom, etc.).
Why UASI?
We believe that investing in our people is key to our success. In return for your talents, we offer a full benefits package, PTO and top pay! Additional benefits include:
- Collaborative, mission-driven team environment.
- Opportunities for continuous learning, education and professional growth.
- Leadership that values your expertise and input
Ready to make a difference and grow your career? We would love to hear from you!
Skills
As published by greenhouse · 11 questions · 1 written answer
Basics
First Name, Last Name, Email, Phone, Resume/CV
Short answers (2)
- Preferred First Name optional
- What is your desired pay? optional
Pick from a list (8)
- What type of position are you interested in?
- Do you have a minimum of 2 years CDI experience?
- Select any current/active certification
- Which systems do you have experience using? optional
- I understand that this position requires all work to be performed from within the United States. I certify that, if hired, I will work from within the United States and that I am legally authorized to work in the United States or will obtain the necessary authorization before beginning employment.
- Are you legally eligible for employment in this country?
- Have you ever been convicted of, or pleaded guilty or no contest (nolo contendere) to, a criminal offense, excluding: a. Arrests not resulting in a conviction; b. Expunged, sealed, or legally dismissed records; c. Juvenile adjudications, where prohibited by law; and d. Any offenses that you are not legally required to disclose under applicable federal, state, or local law?
- Are you able to meet the attendance requirements of this position?
Written answers (1)
- If yes, please provide the date(s), offense(s), and any additional information you would like us to consider: optional