Clinical Documentation Integrity 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

• Registered Nurse (RN) certification
• 2 years of clinical documentation improvement (CDI) experience
• 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.)
• Experience using 3M and Epic preferred but not required

About the Company

UASI is driven by a mission to improve the quality and accuracy of clinical documentation through expert CDI consulting. We are looking for experienced and motivated CDI professionals to join our dedicated team in a fully remote capacity.