HCC Clinical Documentation Specialist

The role

The HCC Clinical Documentation Specialist supports coding accuracy, HCC capture, regulatory compliance, and clinical documentation integrity. This role involves performing prospective reviews of medical records to validate chronic conditions and ensure documentation accuracy.

What you will do

• 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 to validate chronic conditions and ensure documentation accuracy.
• Utilizes Epic and OurPractice Advisories to perform prospective chart reviews.
• Track and manage work queues, review inventories, and OPA-related activities.
• Monitor, analyze, and report CDI outcomes, documentation trends, and HCC recapture performance.

Required qualifications

• Minimum 2 years of ambulatory Clinical Documentation Integrity, Risk Adjustment, or related healthcare documentation experience
• Active LPN or RN license required
• 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.)

Nice to have

• CCDS, CCDS-O, CDIP, CDEO and/or CRC certification strongly preferred
• Proficiency in Epic workflows, including interpretation and management of OurPractice Advisories (OPAs) preferred

Benefits

• full benefits package
• PTO
• top pay
• Collaborative, mission-driven team environment
• Opportunities for continuous learning, education and professional growth
• Leadership that values your expertise and input

About the company

UASI is driven by a mission to improve the quality and accuracy of clinical documentation through expert CDI consulting.