Clinical Documentation Specialist Full Time NEW

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?

Benefits

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!