Clinical Documentation Improvement Specialist

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Regular Full-Time Remote, US

13 days ago Requisition

Salary Range: $68,000.00 To $85,000.00 Annually

Are you passionate about clinical documentation, risk adjustment, and improving the quality of patient care? We're looking for an experienced Clinical Documentation Improvement (CDI) Specialist to join our team and play a critical role in ensuring the accuracy, completeness, and quality of clinical documentation across our organization.

If you're a collaborative problem solver with a strong background in Medicare and Medicaid Risk Adjustment, HCC Coding, Clinical Documentation Improvement, and provider education, we'd love to hear from you.

• Serve as a subject matter expert on ICD-10-CM Coding Guidelines, AHA Coding Clinic guidance, and Risk Adjustment methodologies.
• Conduct proactive medical record reviews to evaluate documentation quality, diagnosis coding accuracy, co-morbidities, complications, and appropriate secondary diagnoses.
• Ensure patient conditions are accurately documented and coded to support quality care and appropriate risk stratification.
• Identify documentation and coding trends impacting patient risk scores and value-based care performance.

• Develop and deliver engaging education programs for providers, coders, and clinical care teams.
• Provide ongoing guidance on documentation best practices, coding updates, compliance requirements, and risk adjustment principles.
• Create educational tools, resources, and training materials that improve coding accuracy and documentation quality.
• Partner with providers to identify opportunities for documentation improvement and workflow optimization.

• Collaborate with contracted health plans on risk adjustment and value-based care initiatives.
• Support auditing activities, review health plan findings, and develop performance improvement plans when needed.
• Participate in clinical quality, revenue cycle, population health, and data analytics initiatives.
• Monitor regulatory, coding, and reimbursement changes and communicate impacts across the organization.

• Analyze documentation and coding trends to identify opportunities for improvement.
• Work closely with clinical leadership, coding teams, health plans, and operational stakeholders.
• Help drive strategies that improve quality scores, risk adjustment accuracy, and overall organizational performance.

• Certified Risk Coder (CRC) through AAPC or CDI/CCS certification through AHIMA.
• Minimum of 3 years of experience in Medicare and/or Medicaid Risk Adjustment, including HHS-HCC, CMS-HCC, or DxCG methodologies.
• Strong experience with ICD-10 coding and clinical documentation review.
• In-depth knowledge of medical terminology, anatomy, physiology, and disease processes.
• Expertise in HCC coding and risk adjustment programs.
• Strong analytical, organizational, and problem-solving skills.
• Excellent written and verbal communication skills with the ability to educate audiences at all levels.
• Ability to manage multiple priorities and work independently in a remote environment.

• Certified Professional Coder (CPC) through AAPC.
• Minimum of 3 years of clinical experience, preferably in a Federally Qualified Health Center (FQHC) or primary care environment.
• Experience with Epic Electronic Medical Record (EMR) systems.
• Experience supporting value-based care and population health initiatives.

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