Clinical Documentation Integrity Specialist

UASI; United States; Remote; USD 80,000 - 100,000; Full time

Benefits offered by this job

Full benefits

PTO

Top pay

Professional growth

Job summary

UASI is seeking a Clinical Documentation Integrity Specialist to support accurate coding, regulatory compliance, and high-quality outcomes in a fully remote capacity. The role focuses on CDI review, physician communication, and documentation improvement in inpatient settings.

The ideal candidate will have an RN license with CDI experience, familiarity with ICD-10-CM and MS-DRGs, and strong analytical and communication skills to collaborate with clinicians and coders.

Qualifications

• Minimum of 2 years of inpatient CDI experience.
• Minimum of 2 years of bedside nursing experience in an acute care setting.
• 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.

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.

Skills

CDI experience

Nursing background

Analytical thinking

Regulatory knowledge

Communication skills

Education

RN license

CDDS/CDIP preferred

Tools

3M software

Epic

MS Office

Job description

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, 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

I understand that this position requires all work to be performed from within the United States. I certify that, if hired, I will work from within the United States and that I am legally authorized to work in the United States or will obtain the necessary authorization before beginning employment.

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.

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.