Clinical Documentation Improvement Jobs
Clinical Documentation Improvement jobs are open across hospitals, health systems, and physician groups, at every level from entry-level specialist to manager and director, with specializations in inpatient coding, risk adjustment, and query management. Find a role that fits from the openings below and apply directly.
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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 OP Clinical Documentation Improvement (CDI) professionals to join our dedicated team in a fully remote capacity.
As an Outpatient Clinical Documentation Improvement (CDI) 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!
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 OP Clinical Documentation Improvement (CDI) professionals to join our dedicated team in a fully remote capacity.
As an Outpatient Clinical Documentation Improvement (CDI) 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!
Clinical Documentation Improvement Jobs by Experience Level
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Find JobsClinical Documentation Improvement Job Market
Who's Hiring
Top Industries Hiring
- Healthcare & Medical Services
What Employers Look For
The qualifications that appear most often in clinical documentation improvement jobs.
- CDIP or CCDS certification, or active pursuit of one
- Minimum three to five years of clinical coding or nursing experience in an acute-care setting
- Proficiency with CDI software platforms such as 3M 360 Encompass or Optum CAC
- Strong working knowledge of ICD-10-CM/PCS coding guidelines and MS-DRG methodology
- Demonstrated ability to write compliant, non-leading physician queries
- Familiarity with quality metrics including PSI, HAC, and mortality indicators
Tips for Your Clinical Documentation Improvement Job Search
Lead your resume with CDI credentials
List your CDIP or CCDS certification prominently at the top of your resume, before your work history. Hiring managers in clinical documentation improvement scan for these credentials first, and burying them in a certifications section at the bottom costs you interviews.
Quantify your query response rates
Replace vague phrases like 'managed physician queries' with concrete outcomes: your case review volume per week, your query agreement rate, and any improvement in CC/MCC capture you drove. Documentation improvement roles reward candidates who can show measurable impact on DRG accuracy.
Apply early to roles that fit
Migrate Mate lists clinical documentation improvement openings from across the United States in one place, so you can find roles that match and apply directly to each listing.
Filter openings by care setting intentionally
Your resume reads differently to an acute-care hospital than to an outpatient risk-adjustment program. Tailor your application language to the setting in each posting, emphasizing inpatient DRG expertise for acute-care roles and HCC coding for value-based or Medicare Advantage positions.
Prepare for a live chart review exercise
Many CDI interviews include a practical scenario where you review a sample patient record and draft a physician query. Practice writing compliant, non-leading queries in the clarification format, and be ready to explain your clinical reasoning for the principal diagnosis you select.
Negotiate with specificity on remote and hybrid terms
Remote CDI roles often have unstated requirements around onsite days for audits or team meetings. Before accepting, ask directly how many onsite days per quarter are expected and whether that applies during Joint Commission surveys or coding audits.
Clinical Documentation Improvement Jobs: Frequently Asked Questions
Which companies are hiring the most clinical documentation improvements?
The companies hiring the most clinical documentation improvements right now include Genesis HealthCare, UASI, and Optum, with the largest share of openings in New York, New Mexico, and Texas, based on current listings on Migrate Mate as of August 2026. Large integrated health systems and national CDI outsourcing firms consistently account for the majority of active postings.
How many clinical documentation improvement jobs are remote?
About 53% of clinical documentation improvement openings are fully remote or hybrid as of August 2026, making it one of the more remote-accessible roles in clinical healthcare. Remote work is most concentrated in concurrent review and risk-adjustment positions, while CDI educator and program director roles are more likely to require onsite presence.
How do you become a clinical documentation improvement specialist?
Start with a clinical foundation in either nursing, coding, or health information management, as employers expect you to read and interpret patient records accurately. From there, gain inpatient or outpatient coding experience, then pursue your CDIP through AHIMA or your CCDS through ACDIS to validate your specialist knowledge. Most entry-level CDI roles require both clinical background and at least a basic understanding of DRG methodology before you apply.
Can I get a clinical documentation improvement job without direct CDI experience?
Yes, employers will hire candidates without dedicated CDI experience if your clinical or coding background is strong. Registered nurses with ICU or hospitalist floor experience and coders who have worked inpatient acute care are the most common career changers into CDI. Highlight your query-writing practice, any CDI shadowing you have completed, and your progress toward a CDIP or CCDS certification to offset the experience gap.
What does the clinical documentation improvement interview process look like?
Most CDI interviews follow a two to three stage process: an initial screening with a recruiter focused on credentials and setting experience, a panel interview with the CDI manager and a senior specialist covering scenario-based questions on query writing and coding logic, and sometimes a practical exercise where you review a deidentified record and draft a compliant query. Some employers also ask you to walk through a case where you changed a working DRG assignment.
Where can I find and apply to clinical documentation improvement jobs?
You can find and apply to clinical documentation improvement jobs on Migrate Mate, which lists current openings from across the United States. Find roles that match your credentials and care setting preference, then apply directly to each listing from the page.
See All 43 Clinical Documentation Improvement Jobs
Find roles that match your experience and apply in just a few clicks.
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