APP Clinical Documentation Integrity Reviewer

The APP Clinical Documentation Integrity (CDI) Reviewer establishes and supports a clinically focused documentation audit and education function within Documentation/Risk Adjustment. Leveraging advanced practice provider clinical judgment, this role evaluates whether medical records contain sufficient clinical evidence to support reported diagnoses, identifies documentation and compliance risks, and delivers peer-level education to improve documentation accuracy, specificity, and defensibility.

The reviewer partners with providers, coding, compliance, clinical leadership, and risk adjustment teams to strengthen audit readiness, reduce repeat findings, and address documentation issues proactively.

• Conduct targeted, risk-based clinical documentation audits of high-risk diagnoses, hierarchical condition categories (HCCs), and other areas of regulatory or organizational focus.

• Evaluate whether documented history, assessment, examination findings, diagnostic results, treatment, monitoring, and plan of care sufficiently support reported diagnoses.

• Identify unsupported, conflicting, nonspecific, or incomplete documentation and distinguish clinical validation concerns from coding accuracy issues.

• Analyze audit findings and documentation trends to identify recurring risks, root causes, and opportunities for process improvement.

• Develop and deliver focused, peer-level provider education and feedback to promote accurate, complete, and compliant documentation practices.

• Escalate complex, ambiguous, or high-risk cases to clinical leadership, compliance, or other appropriate stakeholders for review and resolution.

• Collaborate with coding and documentation teams to support compliant query practices, clarify clinical issues, and reduce avoidable rework and provider burden.

• Maintain accurate audit records, track findings and education outcomes, and prepare reports communicating risk themes, progress, and recommended actions.

• Stay current on relevant CMS guidance, ICD-10-CM conventions, Medicare Advantage risk adjustment requirements, clinical documentation standards, and organizational policies.

• Protect the confidentiality and security of patient information and perform all duties in accordance with applicable laws, regulations, and company policies.

Education
Master’s degree from an accredited advanced practice nursing or physician assistant program.

Experience
Minimum of three years of clinical practice experience as an advanced practice provider. Experience with clinical documentation integrity, risk adjustment, auditing, or provider education is strongly preferred. Experience reviewing complex adult or geriatric medical records is preferred.

Skills
Strong clinical assessment and critical-thinking skills; ability to evaluate documentation against the patient’s clinical picture; knowledge of compliant diagnosis documentation and risk adjustment principles; clear written and verbal communication; effective provider education and feedback skills; sound judgment when escalating risk; attention to detail; ability to analyze trends and manage multiple priorities independently in a remote environment; and proficiency with electronic health records and standard Microsoft Office applications.

Certifications/Licenses
Current, unrestricted license as a Nurse Practitioner, Physician Assistant, or other approved advanced practice provider in at least one U.S. state. National board certification appropriate to the APP discipline is required. Clinical documentation integrity, coding, audit, or risk adjustment certification is preferred.

• Ability to stand or sit for extended…