Outpatient Clinical Documentation Improvement (CDI) Specialist

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 required
• Strong understanding of ICD-10-CM coding guidelines and HCC documentation requirements
• Proficiency with MS Office, VPNs, virtual machines, and video conferencing tools

Preferred Qualifications

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

About the Company

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