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Clinical Documentation Integrity Specialist
Aledade
Casper, WY, USA
Posted on Oct 8, 2025
The Clinical Documentation Integrity Specialist (CDIS) plays a vital role in ensuring the precision and completeness of clinical documentation and coding to optimize patient data accuracy. This position involves performing both retrospective and prospective chart reviews. The CDIS will conduct provider education and training related to complete and accurate diagnostic documentation and coding, in accordance with ICD-10 CM coding guidelines, internal protocols and CMS and payer guidelines. The CDIS will deliver tailored education at the individual provider-level; complete end-to-end workflow assessment and optimization; and perform chart reviews to identify specific opportunities for improved accuracy. There will be opportunity to travel periodically to practices as well as engage in remote work. The CDIS must be detail-oriented, service-minded, possess strong verbal and written communication skills, and be fluent in (or willing and able to master) Google Suite tools.
Primary Duties:
- Perform chart reviews to identify opportunities for better accuracy in clinical documentation and coding. Evaluate and optimize end-to-end practice clinical documentation, billing and coding workflows. Develop and implement action plans to improve the completeness and accuracy of clinical documentation and coding
- Work directly with Aledade practices and providers on continuous improvement of complete and accurate documentation and diagnosis coding. Facilitate clinical documentation and coding communication amongst key internal and external stakeholders. Provide guidance to field staff and practices regarding general documentation and coding best practices and risk adjustment
- Deliver internal and external-facing education and training on clinical documentation and diagnosis coding to support value-based contracts.
Minimum Qualifications:
- Bachelor’s degree in a healthcare related field or equivalent work experience required
- Current certification as a Certified Professional Coder (CPC), or equivalent
- Certified Documentation Expert Outpatient (CDEO®) from AAPC or Certified Clinical Documentation Specialist-Outpatient (CCDS-O) from ACDIS.
- 3+ years of recent, relevant work experience in CDI or 5+ years as a risk adjustment auditor; 3+ years RCM or billing experience
- Familiarity with anatomy and physiology, disease processes and medical terminology
- Thorough understanding of medical coding guidelines and regulations including compliance, reimbursement, and the impact of diagnosis documentation on risk adjustment payment models
- Subject matter expertise on the CMS HCC Risk Adjustment program, methodology, and impact to value-based contracts
- Ability to identify and communicate opportunities to improve documentation and diagnosis capture for accurate risk adjustment coding
- Experience working directly with physician practices and individual providers to achieve demonstrable improvement in increasing the accuracy and completeness of documentation and diagnosis coding
Preferred Qualifications:
- Successful track record in outpatient coding and billing through previous experience
- Self-directed and solution oriented
- Strong understanding of value-based care principles, particularly as they relate to the impact of clinical documentation and coding on risk adjustment payment models in value-based contracts
- Strong understanding of outpatient coding and billing
- Solution-oriented individual who can execute tactical continuous quality improvement work to deliver results in value-based contracts
- Excellent communicator who can articulate the impact of documentation and diagnosis initiatives to Aledade ACO member practices and their key staff (e.g., office managers, practice billers, etc.), and internally within the company.
- Ability to work collaboratively across Aledade clinical and non-clinical teams to gain buy-in and implement key documentation improvement initiatives
- References demonstrating high degree of integrity and professional accountability
Physical Requirements:
- Prolonged periods of sitting at a desk and working on a computer