Outpatient Clinical Documentation Improvement (CDI) Specialist
UASI
Outpatient Clinical Documentation Improvement (CDI) Specialist Remote 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 OP Clinical Documentation Improvement (CDI) professionals to join our dedicated team in a fully remote capacity. As an Outpatient Clinical Documentation Improvement (CDI) Specialist, this individual will play a critical role in supporting coding accuracy, HCC capture, regulatory compliance, and clinical documentation integrity. This role requires strong clinical judgment, analytical skills, and a commitment to advancing documentation excellence that reflects the patient's true severity of illness and complexity of care. Key Responsibilities Serves as a subject matter expert in clinical documentation quality, risk adjustment, and HCC coding integrity in the outpatient setting. Performs prospective reviews of medical records from physician practices, outpatient settings, and relevant inpatient encounters to validate chronic conditions and ensure documentation accuracy, clinical integrity, appropriate coding, and HCC capture. Utilizes Epic, OurPractice Advisories (OPAs) to perform prospective chart reviews, identify documentation opportunities, validate chronic conditions, and support accurate coding, HCC capture, and clinical documentation integrity initiatives. Track and manage work queues, review inventories, and OPA-related activities to ensure timely follow-up, productivity targets, and accurate completion of CDI interventions. Monitor, analyze, and report CDI outcomes, documentation trends, and HCC recapture performance to identify improvement opportunities and support program goals. Qualifications: Minimum 2 years of ambulatory Clinical Documentation Integrity, Risk Adjustment, or related healthcare documentation experience Active LPN or RN license required CCDS, CCDS-O, CDIP, CDEO and/or CRC certification strongly preferred Proficiency in Epic workflows, including interpretation and management of OurPractice Advisories (OPAs) preferred Strong understanding of: ICD-10-CM coding guidelines, HCC documentation and coding requirements Strong understanding of clinical criteria for HCC diagnoses 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! U.S. Standard Demographic Questions We invite applicants to share their demographic background. If you choose to complete this survey, your responses may be used to identify areas of improvement in our hiring process. Voluntary Self-Identification For government reporting purposes, we ask candidates to respond to the below self-identification survey.Completion of the form is entirely voluntary. Whatever your decision, it will not be considered in the hiringprocess or thereafter. Any information that you do provide will be recorded and maintained in aconfidential file. As set forth in UASI’s Equal Employment Opportunity policy,we do not discriminate on the basis of any protected group status under any applicable law. If you believe you belong to any of the categories of protected veterans listed below, please indicate by making the appropriate selection.As a government contractor subject to the Vietnam Era Veterans Readjustment Assistance Act (VEVRAA), we request this information in order to measurethe effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA. Classification of protected categoriesis as follows: A \"disabled veteran\" is one of the following: a veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or a person who was discharged or released from active duty because of a service-connected disability. A \"recently separated veteran\" means any veteran during the three-year period beginning on the date of such veteran's discharge or release from active duty in the U.S. military, ground, naval, or air service. An \"active duty wartime or campaign badge veteran\" means a veteran who served on active duty in the U.S. military, ground, naval or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense. An \"Armed forces service medal veteran\" means a veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985. #J-18808-Ljbffr
$39.4 - $51.47 per hour
...includes two hospitals, an outpatient center, satellite ED,... ...- $51.47 Facilitates improvement of overall quality and completeness of clinical documentation in patient record... ...Documentation Specialist (CCDS) or Certified Documentation... ...necessary to perform CDI. Flexible, dependable...SuggestedFull timeTemporary workPart timeFlexible hours- ...Health Sciences University is seeking a full-time TH Utilization Review & Quality Assurance Senior Coordinator / Clinical Documentation Improvement (CDI) Specialist. Job Summary Reporting to the CDI Manager and Director of Health Information Management, the CDI...SuggestedFull timeWork at office
- ...Health Sciences University is seeking a full-time TH Utilization Review & Quality Assurance Senior Coordinator / Clinical Documentation Improvement (CDI) Specialist. Job Summary Reporting to the CDI Manager and Director of Health Information Management, the CDI Specialist...SuggestedFull timeWork at office
- ...CorroHealth, Inc. seeks a CDI Specialist to collaborate with physicians and medical records teams to improve documentation quality for DRG accuracy and patient care outcomes. You will review clinical records, identify documentation gaps, and place queries per AHIMA guidelines...SuggestedRemote work
$79.72k - $108.71k
...Description Job Description The Clinical Documentation Quality Improvement Specialist II is responsible for improving the... ...2-4 years recent experience in CDI role 2. To meet quality and quantity... ...eight hospitals, more than 400 outpatient practices, more than 300 labs, a...SuggestedFull timeTraineeshipLocal area$60.2k - $107.4k
...The work you do with our team will directly improve health outcomes by connecting people with the... ...start Caring. Connecting. Growing together. The Clinical Document Improvement Specialist (CDS) is responsible for providing CDI program oversight and day to day CDI...Minimum wageFull timeWork experience placementLocal areaRemote work- Capital Health seeks a Registered Nurse with a CDI focus to improve clinical documentation quality across patient records, partnering with physicians, nurses, and coding staff to ensure accurate DRG assignment and mortality risk reporting. The role requires 2+ years in...Full time
- ...Mount Sinai Health System invites a Clinical Documentation Specialist to enhance the quality and completeness of outpatient documentation and coding. You will review ambulatory... ...physicians, HIM, and the CDQI team to improve accuracy and completeness of clinical data....
- ...Health Sciences University is seeking a full-time TH Utilization Review & Quality Assurance Senior Coordinator / Clinical Documentation Improvement (CDI) Specialist within the Department of Health Information Management. The CDI Specialist reviews inpatient records to...Full time
$55.85 - $74 per hour
...Brief Overview The Relief Clinical Documentation Integrity Specialist I uses clinical and... ...reviews of inpatient and/or outpatient medical records to evaluate... ...identifying opportunities for improving the quality of medical... ...the more routine CDI work and in a learning capacity...Hourly payTraineeshipWork experience placementLocal area- ...GeBBS Healthcare Solutions, Inc. is seeking a Clinical Documentation Specialist for a 6-month remote project. The role supports accuracy of clinical... ...settings, collaborating with physicians, nurses, coders, and CDI professionals. The ideal candidate will have an RN or LPN...Remote work
- UASI is seeking a Clinical Documentation Integrity Specialist to join our fully remote CDI team in the United States. The role focuses on improving documentation accuracy, ensuring regulatory compliance, and supporting high-quality patient outcomes through physician queries...Remote job
$84 per hour
...Dorsey . Position: Clinical Documentation Integrity (CDI) Leader Type: Contract... ...for inpatient and outpatient settings. Oversee concurrent... ...clinical documentation improvement suggestions for accuracy... ...Clinical Documentation Specialist) or CDIP (Clinical Documentation...Contract workSummer workRemote work- Adventist HealthCare seeks a Clinical Documentation Specialist to ensure accurate, complete documentation reflecting patient status. You will query providers... ...degree, and 5+ years inpatient clinical experience with CDI exposure. Remote day shift with full-time schedule. #J-18...Remote jobFull timeDay shift
- Capital Health seeks a Clinical Documentation Specialist to improve the quality and completeness of clinical documentation across patient records, ensuring accurate DRG assignments and quality reporting. Strong communication with physicians and care teams is essential....
- ...CorroHealth, Inc. in the United States is seeking a CDI Specialist to collaborate with physicians, nursing staff, and medical records coding staff to improve documentation quality, accuracy and completeness for DRG assignment, severity of illness, and case mix data. The...Remote work
$65.89k - $98.83k
...Description MSHPseeks a Clinical Documentation Specialist who will support efforts to improve the overall quality and completeness of clinical documentation and coding in outpatient physician practices. They will work closely with physicians, Health Information Management...TraineeshipWork at officeLocal areaRemote work- ...The RN – Clinical Documentation Specialist I at MUSC conducts reviews of inpatient records to identify missing or vague diagnoses and collaborates with... ...experience including pediatric inpatient/ED, and involves CDI responsibilities and quality metrics. #J-18808-Ljbffr...
$86k
Job Title: Clinical Documentation Integrity Specialist (FMG, DO or MD) Compensation Salary Range: $86,000+ per year... ..., expertise in documentation improvement, and the ability to educate providers... ...responses Analyze, monitor, and report CDI metrics while identifying...Contract workShift workDay shift- Clinical Documentation Integrity Specialist Remote 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,...For contractorsRemote work
- Remote Clinical Documentation Specialist United States Trending Job Description Job Summary The Clinical Documentation Specialist (CDS) performs clinical documentation improvement (CDI) activities to support the accuracy, quality, and completeness of patient records at...Remote jobFull timeShift work
$50 - $150 per hour
..., General Catalyst , Peter Thiel , Adam D'Angelo , Larry Summers , and Jack Dorsey . Position: Clinical Documentation Integrity (CDI) Specialist Type: Contract Compensation: $50–$150/hour Location: Remote Role Responsibilities Review...Contract workSummer workRemote work- ...CDI Specialists will collaborate extensively with physicians, nursing... ...medical records coding staff to improve the quality, specificity,... ...and completeness of the documentation of care provided and coded.... ...complete documentation of clinical information used for measuring...Full timeWork at officeRemote work
- ...experience? Minimum 2–3 years of inpatient CDI experience Experience performing... ...escalation, and query compliance Experience with clinical validation and complex inpatient cases Strong knowledge of inpatient documentation improvement, severity of illness (SOI), and risk of...Permanent employmentFull timeRemote workWork visa
- ...SUNY Downstate Health Sciences University seeks a full-time CDI Specialist within the Department of Health Information Management in New... ...with physicians, residents, and coding staff to drive documentation quality. Ideal candidates have a NY RN license with acute care...Full time
- ...full-time TH Medical Records Specialist / Outpatient Coding Specialist. Job... ...abstracts relevant clinical information and assigns appropriate... ...codes to ensure accurate documentation, coding compliance, and... ...staff education, and process improvement initiatives, as assigned....Full time
- ...ResponsibilitiesPurpose of Position: Under the direction of the Director of Clinical Documentation, Director of Health Information Management or a designee... ...procedures, and standards of care for better outcomes and improved patient experience. Demonstrates effective communication,...Remote work
- ...The University of Miami Health System is seeking a Clinical Documentation Specialist I (CDI I) to perform concurrent and retrospective reviews of inpatient records. The role focuses on accurate documentation of severity of illness and risk mortality, with collaboration...
- ...BronxCare in New York seeks a professional for Clinical Documentation Improvement. Responsibilities include reviewing clinical documentation, interacting with patients and staff, and participating in quality improvement activities. The ideal candidate should hold a Bachelor...
- ...Mental Health Center, part of NYC Health + Hospitals, seeks a Clinical Documentation Specialist to optimize clinical record documentation for appropriate... ...with physicians, coding staff, and leadership to improve documentation accuracy and DRG assignment. Required qualifications...
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