Clinical Documentation Specialist – Outpatient

Reveleer

. Facilitate improvement in the overall quality and completeness of Clinical Intelligence’s recapture and suspecting performance .

Posted 9/21/2026full-timeRemote • United StatesJuniorMid-Level💰 $85,000 - $120,000 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in Clinical Documentation Improvement (CDI) with a strong focus on Hierarchical Condition Category (HCC) validation, risk adjustment outcomes, and compliance with industry standards. Proficient in utilizing electronic medical records systems to enhance documentation accuracy and support clinical workflows.

Highest-signal resume keywords

Registered Nurse LicenseCertified Documentation Expert-Outpatient (CDEO)Certified Clinical Documentation Specialist-Outpatient (CCDS-O)Certified Risk Adjustment Coder (CRC)Outpatient CDI Experience

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical Documentation Improvement (CDI)HCC ValidationICD-10-CM CodingMedical TerminologyClinical Evidence ValidationDocumentation Gap IdentificationRisk Adjustment OutcomesQuery CreationClinical Logic ImprovementWorkflow Formulation

Tools & Technologies

Epic EMRAthena EMRCerner EMRElectronic Medical Records

Certifications & Qualifications

Registered Nurse LicenseCertified Documentation Expert-Outpatient (CDEO)Certified Clinical Documentation Specialist-Outpatient (CCDS-O)Certified Documentation Improvement Practitioner (CDIP)Certified Risk Adjustment Coder (CRC)

Industry Keywords

CMSHHSMedicaidRx HCC ModelsAHA Coding ClinicsOfficial Coding GuidelinesAmbulatory Clinical Experience

About the role

Key responsibilities & impact

Facilitate improvement in the overall quality and completeness of Clinical Intelligence’s recapture and suspecting performance
Review patient records to identify and validate Hierarchical Condition Category (HCC) diagnoses
Query providers to ensure accurate and complete documentation supporting HCC and condition-related diagnoses
Enhance RAF score accuracy and improve risk adjustment outcomes
Apply medical terminology, disease process, treatment modality, diagnostic test, medication, and procedure knowledge to identify documentation gaps
Validate recapture and suspect conditions based on clinical evidence
Validate that documentation supports reported conditions
Create queries reflecting best practice
Formulate recommendations to improve clinical logic and workflows
Maintain strict confidentiality of patient information in accordance with privacy regulations

Requirements

What you’ll need

Graduate of an accredited nursing education program
Active and unrestricted Registered Nurse or Advanced Practice Provider license
Certified Documentation Expert-Outpatient (CDEO) or Certified Clinical Documentation Specialist- Outpatient (CCDS-O) or Certified Documentation Improvement Practitioner (CDIP) and Certified Risk Adjustment Coder (CRC)
Minimum of 2 years outpatient CDI experience
Experience navigating Epic, Athena, and Cerner EMRs
5 years of clinical experience
Strong understanding of CMS, HHS, Medicaid, and Rx HCC models
Up to date with industry standards related to HCC documentation, ICD-10-CM coding, AHA Coding Clinics, and Official Coding Guidelines
Proficient in the use of electronic medical records and technology enabling solutions
Bachelor’s Degree in Nursing preferred
Ambulatory clinical experience preferred
Must complete E-Verify requirements for new hires

Benefits

Comp & perks

Competitive salary
Medical, Dental and Vision benefits
401k match
Generous PTO plan