Clinical Documentation Improvement Specialist

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

Requirements

• 2 years of clinical documentation improvement (CDI) experience
• Registered Nurse (RN) certification
• Knowledge of ICD-10-CM, MS-DRGs, coding guidelines, and compliance standards
• Proficiency with MS Office, VPNs, virtual machines, and video conferencing tools

Preferred Qualifications

• Experience using 3M
• Experience using Epic

Benefits

• Full benefits package
• Paid Time Off (PTO)
• Opportunities for continuous learning and professional growth

About the Company

At UASI, we're driven by a mission to improve the quality and accuracy of clinical documentation through expert CDI consulting.