Clinical Documentation Improvement Specialist

About This Role

This fully remote role is for an experienced and motivated Clinical Documentation Improvement (CDI) professional who will help improve the quality and accuracy of clinical documentation. The position supports the accuracy of coded data, compliance with regulatory requirements, and the improvement of clinical outcomes reporting. It suits a candidate with a clinical background, strong analytical skills, and a passion for accurate and compliant clinical documentation.

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

Requirements

• 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.)
• Certification: Registered Nurse (RN) 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.)

Nice to have:

• Utilization of 3M and Epic software
• CCDS/CDIP certification

Benefits

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

About the Company

UASI is driven by a mission to improve the quality and accuracy of clinical documentation through expert CDI consulting.