Outpatient Clinical Documentation Integrity Specialist

JOB SUMMARY

The Outpatient Clinical Documentation Integrity (CDI) Specialist improves the accuracy, completeness, and compliance of clinical documentation and coding across the organization’s multi-facility PACE healthcare system. This role conducts prospective, concurrent, and retrospective chart reviews to support HCC capture, RAF accuracy, ICD-10-CM coding, quality outcomes, and regulatory compliance. The CDI Specialist partners with providers, coding professionals, finance, revenue cycle, and interdisciplinary teams to ensure diagnoses are clinically supported and appropriately documented while providing compliant education, queries, and feedback that strengthen documentation quality and accurately reflect participant acuity and complexity.

ESSESNTIAL DUTIES AND RESPONSIBILITIES:

• Performs prospective, concurrent, and retrospective chart reviews across outpatient, home, inpatient, skilled nursing, and post-acute settings to identify documentation gaps and improvement opportunities.
• Supports compliant HCC capture and RAF accuracy for Medicare Advantage, Medicaid, and PACE populations using current CMS risk-adjustment models and guidelines.
• Identifies opportunities to improve diagnosis specificity, chronic condition documentation, annual HCC recapture, and accurate reporting of participant acuity and complexity.
• Ensures diagnoses are clinically supported, meet CMS documentation requirements and MEAT criteria, and include appropriate clinical linkages when documented by the provider.
• Conducts pre-visit reviews to identify suspected conditions, recapture opportunities, and documentation needs for provider consideration.
• Develops compliant provider queries when documentation requires clarification or additional specificity.
• Collaborates with coding professionals to ensure documentation supports accurate ICD-10-CM coding, HCC assignment, procedures, modifiers, place of service, and other encounter elements.
• Educates providers on documentation specificity, chronic condition capture, risk adjustment, and CMS requirements through collaborative and non-punitive feedback.
• Partners with clinical, coding, quality, compliance, finance, revenue cycle, and operational teams to improve documentation integrity, coding accuracy, and care planning.
• Participates in documentation audits and quality assurance activities and supports preparation for CMS RADV, payer, and regulatory audits.
• Monitors documentation and coding trends, reports findings, and recommends workflow and process improvements.
• Evaluates EHR workflows, documentation templates, and reporting tools to improve documentation accuracy and efficiency.
• Maintains compliance with CMS regulations, ICD-10-CM Official Guidelines, organizational policies, and ethical documentation standards.
• Maintains current knowledge of CDI, risk-adjustment methodologies, coding updates, and documentation best practices through ongoing professional development.

Metrics for Success

• Improvement in HCC capture and annual HCC recapture rates.
• Increased documentation meeting MEAT criteria.
• Improved RAF accuracy.
• Reduction in vague, unspecified, or unsupported diagnoses.
• Improved ICD-10-CM documentation specificity.
• Positive internal and external audit performance.
• Improved provider documentation following educational interventions.
• Accurate and timely completion of chart reviews and provider queries.

EXPERIENCEAND EDUCATION

• Active, unrestricted RN, PA, NP, MD/DO, or other clinically licensed healthcare professional license preferred (or equivalent clinical documentation experience as approved by the organization).
• CCDS, CDIP, CCS, CPC, CRC, or other CDI/coding certification preferred.
• Minimum of three (3) years of clinical documentation improvement, outpatient CDI, risk adjustment, HCC coding, or related healthcare documentation experience.
• Experience with Medicare Advantage, Medicaid, and/or PACE populations preferred.
• Strong knowledge of ICD-10-CM Official Coding Guidelines, CMS Risk Adjustment methodology, HCCs, RAF scoring, and MEAT documentation principles.
• Experience performing prospective, concurrent, and retrospective chart reviews.
• Experience collaborating with physicians, nurse practitioners, physician assistants, coding professionals, and interdisciplinary healthcare teams.

PRE-EMPLOYMENT REQUIREMENTS:

• Must have reliable transportation, a valid driver's license, and the minimum state required liability auto insurance.
• Be medically cleared for communicable diseases and have all immunizations up to date before engaging in direct participant contact.
• Pass a comprehensive criminal background check that may include, but is not limited to, federal and state Medicare/Medicaid exclusion lists, criminal history, education verification, license verification, reference check, and drug screen.

SKILLS AND ABILITIES:

• Demonstrates strong analytical and critical-thinking skills when reviewing complex clinical documentation, identifying gaps, and supporting accurate HCC capture and RAF scoring.
• Applies detailed knowledge of CMS risk-adjustment requirements, ICD-10-CM guidelines, HCC models, MEAT criteria, and compliant documentation practices.
• Communicates documentation opportunities clearly, respectfully, and constructively while Seeking to Understand provider workflows and clinical decision-making.
• Builds collaborative relationships with providers, coding, quality, compliance, finance, revenue cycle, and operational teams, consistently placing People First.
• Demonstrates sound judgment, integrity, and accountability by choosing to Do the Right Thing and maintaining ethical, clinically supported, and audit-ready documentation practices.
• Is organized and detail-oriented, with the ability to independently prioritize and complete accurate, timely chart reviews, provider queries, audits, and follow-up activities in a remote environment.
• Strives to Exceed Expectations by identifying trends, recommending practical improvements, and supporting measurable gains in documentation quality and coding accuracy.
• Is willing to Be Bold by respectfully addressing documentation concerns, recommending improvements, and adapting to evolving CMS regulations, risk-adjustment models, and organizational needs.