Clinical Risk Adjustment Documentation Specialist

UASI; United States; Remote; USD 70,000 - 110,000; Full time

Benefits offered by this job

Full benefits package

Paid time off (PTO)

Top pay

Job summary

UASI is seeking a Clinical Risk Adjustment Documentation Specialist to join our team remotely in the United States. You will focus on improving clinical documentation quality, HCC capture, and coding integrity in outpatient settings.

Responsibilities include prospective chart reviews, leveraging Epic and OPAs, and tracking CDI outcomes. Requires active LPN/RN license and at least 2 years of ambulatory CDI experience.

Qualifications

• Minimum 2 years of ambulatory CDI or related documentation experience.
• Active LPN or RN license is required.
• CDDS, CCDS-O, CDIP, CDEO or CRC certifications strongly preferred.
• Proficiency with Epic workflows and OPAs preferred.
• Strong understanding of ICD-10-CM guidelines and HCC requirements.

Responsibilities

• Serve as SME in clinical documentation quality, risk adjustment, and HCC coding integrity.
• Perform prospective chart reviews to validate conditions and ensure accuracy.
• Use Epic and OPAs to identify opportunities and support CDI initiatives.
• Track work queues, manage inventories, and ensure timely CDI interventions.
• Monitor and report CDI outcomes and trends to support program goals.

Skills

Ambulatory CDI experience

HCC coding knowledge

ICD-10-CM guidelines

Communication and critical thinking

Documentation accuracy

Education

LPN or RN license

Tools

Epic workflows

OPAs / OurPractice Advisories

Job description

Clinical Risk Adjustment Documentation 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 Clinical Risk Adjustment Documentation Specialists to join our dedicated team in a fully remote capacity.

As a Clinical Risk Adjustment Documentation 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

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.

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.