Outpatient Clinical Documentation Improvement (CDI) Specialist

UASI; Oregon; Hybrid; USD 70,000 - 95,000; Full time

Benefits offered by this job

Full benefits package

PTO

Top pay

Job summary

UASI is seeking an Outpatient Clinical Documentation Improvement (CDI) Specialist to join our team in a fully remote capacity. You will support coding accuracy, HCC capture, regulatory compliance, and documentation integrity with strong clinical judgment and analytical skills.

Responsibilities include prospective reviews, use of Epic and OPAs, and monitoring CDI outcomes to drive improvements. A minimum of 2 years in ambulatory CDI with an active LPN/RN license is required.

Qualifications

• Minimum 2 years of ambulatory Clinical Documentation Integrity, Risk Adjustment, or related healthcare documentation experience.
• Active LPN or RN license required.
• Proficiency with ICD-10-CM coding guidelines and HCC documentation is essential.

Responsibilities

• Serve as SME in outpatient CDI, risk adjustment, and HCC coding integrity.
• Perform prospective reviews of medical records to validate chronic conditions and accurate coding.
• Utilize Epic workflows and OPAs to identify documentation opportunities and support accurate coding.
• Track work queues and ensure timely CDI interventions and productivity targets.
• Monitor and report CDI outcomes and documentation trends to identify improvements.

Skills

Ambulatory CDI experience

LPN or RN license

Education

RN or LPN licensure

Tools

Epic workflows

OPAs (OurPractice Advisories)

MS Office

Job description

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 OP Clinical Documentation Improvement (CDI) professionals to join our dedicated team in a fully remote capacity. As an Outpatient Clinical Documentation Improvement (CDI) 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