HCC Clinical Documentation Specialist

About the Company

At UASI, we're driven by a mission to improve the quality and accuracy of clinical documentation through expert CDI consulting. We provide dedicated services to ensure documentation reflects the patient's true severity of illness and complexity of care.

Responsibilities

• Serve as a subject matter expert in clinical documentation quality, risk adjustment, and HCC coding integrity in the outpatient setting
• Perform prospective reviews of medical records to validate chronic conditions and ensure documentation accuracy and HCC capture
• Utilize Epic and OurPractice Advisories (OPAs) to perform prospective chart reviews and identify documentation opportunities
• Track and manage work queues, review inventories, and OPA-related activities to ensure timely follow-up and productivity
• Monitor, analyze, and report CDI outcomes, documentation trends, and HCC recapture performance

Requirements

• Minimum 2 years of ambulatory Clinical Documentation Integrity, Risk Adjustment, or related healthcare documentation experience
• Active LPN or RN license
• Strong understanding of ICD-10-CM coding guidelines and HCC documentation requirements
• Proficiency with MS Office, VPNs, and video conferencing tools

Preferred Qualifications

• CCDS, CCDS-O, CDIP, CDEO and/or CRC certification
• Proficiency in Epic workflows and OurPractice Advisories (OPAs)