Clinical Documentation Improvement Specialist

Job not on LinkedIn

🕒 4 days ago

🇺🇸 United States – Remote

⏰ Full Time

🟢 Junior

🟡 Mid-level

🏥📝 Medical Writer

👻 Ghost score 15%

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UASI

WebsiteLinkedInAll Job Openings

501 - 1000 employees

Founded 1984

🏥 Healthcare

💼 Consulting

🤝 B2B

💰 $7M Debt on 2020-05

Healthcare • Consulting • B2B

UASI is a healthcare-focused revenue cycle consulting and services firm that helps hospitals and health systems optimize coding, clinical documentation improvement (CDI), denials and revenue integrity, quality and risk management, and AI adoption. With 40+ years of experience, UASI offers consulting, program design and implementation, assessments and audits, managed services and staffing, technology, and education and training. The company serves more than 1,250 hospital facilities and physician groups and employs 800+ nationally credentialed experts; it is KLAS-recognized and positions itself to find and fill gaps, fix processes, or run functions on behalf of clients (domestic, offshore, or both).

📋 Description

• 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

• Minimum of 2 years of inpatient clinical documentation improvement (CDI) experience • Minimum of 2 years of bedside nursing experience in an acute care setting (ICU, Med/Sure, ED, Etc.) • Registered Nurse (RN) certification required • CCDS/CDIP certification preferred but not required • 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.) • Utilization of 3M and Epic software preferred but not required

🏖️ Benefits

• Full benefits package • PTO • Top pay • Collaborative, mission-driven team environment • Opportunities for continuous learning, education and professional growth • Leadership that values your expertise and input • Fully remote work capacity

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