Clinical Documentation Specialist

UASI; United States; On-site; USD 70,000 - 90,000; Full time

Benefits offered by this job

Full benefits package

PTO

Opportunities for continuous learning

Job summary

A leading healthcare consulting firm is looking for a Clinical Documentation Specialist to join their remote team. The ideal candidate will have an RN certification and experience in clinical documentation improvement. Responsibilities include reviewing medical records for accuracy, collaborating with healthcare teams, and identifying opportunities for enhancing documentation quality. The role offers a collaborative environment with a focus on professional growth and a comprehensive benefits package.

Qualifications

• 1-2 years of clinical documentation improvement (CDI) experience required.
• Knowledge of ICD-10-CM, MS‑DRGs, coding guidelines, and compliance standards necessary.
• Comfortable using virtual tools and communication platforms.

Responsibilities

• Review and evaluate medical record documentation for accuracy.
• Collaborate with healthcare professionals for proper documentation.
• Identify documentation improvement opportunities for coding accuracy.

Skills

Clinical documentation improvement skills

Excellent communication

Critical thinking

Organizational skills

Education

Registered Nurse (RN)

Tools

MS Office

3M

Epic

MS Teams

Zoom

Job description

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 Specialists 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

• Experience: 1-2 years of clinical documentation improvement (CDI) experience.
• Certification: Registered Nurse (RN).
• 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.).
• Experience using 3M and Epic preferred but not required.

Why UASI?

We believe that investing in our people is key to our success.

Benefits

• Collaborative, mission‑driven team environment.
• Opportunities for continuous learning, education and professional growth.
• Leadership that values your expertise and input.
• Full benefits package, PTO and top pay!

Ready to make a difference and grow your career? We would love to hear from you!