Outpatient Clinical Documentation Improvement (CDI) Specialist

UASI; United States; Remote; USD 75,000 - 110,000; Full time

Benefits offered by this job

Collaborative team environment

Continuous learning & growth

Leadership that values expertise

Job summary

UASI is seeking an Outpatient CDI Specialist to support coding accuracy and HCC capture in a fully remote capacity. The role emphasizes clinical judgment and documentation integrity.

You will review records from physician practices, utilize Epic/OPAs, and monitor CDI outcomes. Strong RN/LPN license and at least 2 years ambulatory CDI experience are required.

Compensation includes full benefits, PTO, and opportunities for professional growth.

Qualifications

• Minimum 2 years in ambulatory CDI or related healthcare documentation.
• Active LPN or RN license required.
• Certifications (CCDS, CCDS-O, CDIP, CDEO, CRC) preferred.
• Proficient in Epic workflows and OPAs.
• Strong ICD-10-CM and HCC knowledge.

Responsibilities

• Serve as SME in outpatient clinical documentation quality and HCC coding.
• Perform prospective reviews of records to validate chronic conditions and accuracy.
• Use Epic and OPAs to identify opportunities and support coding integrity.
• Track work queues and ensure timely CDI interventions.
• Monitor CDI outcomes and reporting to identify improvements.

Skills

Ambulatory CDI

RN/LPN license

HCC coding

ICD-10-CM knowledge

Epic/OPAs

Communication

Education

RN or LPN license

Tools

Epic

OPAs

Job description

Outpatient Clinical Documentation Improvement (CDI) 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 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

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

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