Clinical Documentation Specialist

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?

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