HCC Clinical Documentation Specialist

Requirements

• 2+ years of ambulatory Clinical Documentation Integrity (CDI) experienceMust
• Active LPN or RN licenseMust
• Strong understanding of ICD-10-CM coding guidelinesMust
• Strong understanding of HCC documentation and coding requirementsMust
• Strong understanding of clinical criteria for HCC diagnosesMust
• Excellent communication skillsMust
• Critical thinking and analytical skillsMust
• Strong organizational skillsMust
• Proficiency with MS Office, email, VPNs, and virtual machinesMust
• Ability to use video conferencing tools (MS Teams, Zoom)Must
• Clinical judgment and commitment to documentation excellenceMust
• CCDS, CCDS-O, CDIP, CDEO, or CRC certification
• Proficiency in Epic workflows and OurPractice Advisories (OPAs)

What you'll do

• Performs prospective reviews of medical records to validate chronic conditions and ensure documentation accuracy
• Utilizes Epic and OurPractice Advisories to identify documentation opportunities and support HCC capture
• Tracks and manages work queues and review inventories to ensure timely follow-up and productivity targets
• Monitors, analyzes, and reports CDI outcomes and HCC recapture performance
• Serves as subject matter expert in clinical documentation quality and risk adjustment

Keywords

About the role

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 HCC Clinical Documentation Specialists to join our dedicated team in a fully remote capacity. As an HCC Clinical Documentation 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! Originally posted on Himalayas