Clinical Documentation Improvement Specialist

UASI; United States; À distance; USD 85 000 - 120 000; Plein temps

Avantages offerts par ce poste

Full benefits package

PTO and top pay

Remote work across the U.S.

Résumé du poste

UASI is seeking a Clinical Documentation Improvement Specialist for a fully remote role in the United States. The candidate will review medical records, collaborate with clinicians and coders, and drive documentation quality to improve coding accuracy and reimbursement.

The ideal applicant has inpatient CDI experience, bedside nursing in acute care, and RN licensure. Familiarity with 3M and Epic software is preferred, with CCDS/CDIP encouraged but not mandatory.

Qualifications

• Minimum 2 years inpatient CDI experience
• Minimum 2 years bedside nursing in acute care (ICU/Med/Surg/ED)
• Knowledge of ICD-10-CM, MS-DRGs, coding guidelines, and compliance standards
• Certification: RN required; CCDS/CDIP preferred but not required
• Familiarity with MS Office, email, VPNs, and video conferencing tools

Responsabilités

• 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

Connaissances

CDI experience

RN bedside nursing

ICD-10-CM knowledge

MS-DRGs knowledge

3M/Epic software

communication

MS Office

Formation

Registered Nurse license (RN)

Outils

3M

Epic

Description du poste

Clinical Documentation Improvement 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, we’re looking for experienced and motivated Clinical Documentation Improvement (CDI) professionals to join our dedicated team in a fully remote capacity.

This role is critical to supporting the accuracy of coded data, compliance with regulatory requirements, and improving the quality of clinical outcomes reporting. The ideal candidate will have a clinical background, excellent analytical skills, and a passion for ensuring accurate and compliant clinical documentation.

Key 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.

Qualifications:

• 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.)
• Utilization of 3M and Epic software preferred (but not required)
• Certification: Registered Nurse (RN) required and CCDS/CDIP 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.).

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!

A criminal conviction does not automatically disqualify an applicant from employment. Any criminal history will be considered only as permitted by applicable law and, where appropriate, in relation to the responsibilities of the position.

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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.

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