The Senior Clinical Documentation Integrity (CDI) & Coding Specialist will support clinical documentation accuracy, HEDIS quality measurement, risk adjustment, and coding integrity across health plan operations.This position will serve as an internal coding and documentation subject matter expert, working collaboratively with Quality Improvement, Utilization Management, Clinical Operations, Provider Relations, and other departments.
The specialist will utilize Inovalon solutions to support HEDIS medical record retrieval and abstraction, clinical data validation, risk adjustment, and identification of coding and documentation opportunities. The position will also support the development of standardized workflows, provider education, and internal coding capabilities. | This is a Remote Role | Monday-Friday, 8:00 AM-4:30 PM.
Performance Responsibilities and Standards:Clinical Documentation Integrity & Coding- Review medical records to evaluate documentation completeness, clinical specificity, and coding accuracy.
- Validate ICD-10-CM, CPT, CPT II, and HCPCS coding against supporting clinical documentation and applicable coding guidelines.
- Identify missing, inconsistent, or unsupported documentation and recommend compliant clarification or correction.
- Conduct prospective and retrospective coding reviews.
- Support coding audits, documentation improvement initiatives, and regulatory compliance.
- Serve as an internal coding resource for clinical, quality, and operational teams.
HEDIS & Quality Improvement- Support HEDIS medical record review, abstraction, and validation activities.
- Identify documentation supporting HEDIS measure compliance and appropriate gap closure.
- Review clinical records for services completed but not accurately represented in available clinical or claims data.
- Evaluate coding opportunities involving CPT II, procedure, and diagnosis codes relevant to quality reporting.
- Support supplemental data validation, medical record audits, and data reconciliation.
Risk Adjustment & HCC Coding- Review medical records to validate risk-adjustable diagnoses and supporting clinical documentation.
- Identify documentation gaps, coding inaccuracies, and opportunities for compliant provider clarification.
- Support CMS-HCC coding accuracy and risk adjustment data integrity.
- Conduct prospective and retrospective risk adjustment reviews.
- Assist with risk adjustment audits, coding validation, and documentation improvement initiatives.
- Collaborate with provider-facing teams to strengthen documentation of chronic and complex conditions.
Required Qualifications:- Active CPC, CCS, CRC, or equivalent nationally recognized coding certification.
- Minimum 3-5 years of relevant experience in medical coding, clinical documentation improvement, risk adjustment, or clinical data validation.
- Strong knowledge of ICD-10-CM coding guidelines and clinical documentation requirements.
- Experience with Medicare Advantage, Managed Care, or Health Plan operations.
- Working knowledge of HEDIS quality measurement and CMS-HCC risk adjustment methodologies.
- Experience reviewing medical records for coding accuracy and documentation completeness.
- Strong analytical, communication, and problem-solving skills.
- Ability to work independently and collaborate across multiple departments
Preferred Qualifications: - Experience with HEHands-on experience with Inovalon solutions supporting both HEDIS and risk adjustment workflows.
- DIS medical record retrieval, abstraction, and validation.
- Familiarity with NCQA HEDIS specifications, CMS requirements, and audit processes.
- Experience supporting D-SNP or I-SNP populations.
- Knowledge of CPT II codes and quality-related claims reporting.
- CCDS, CDIP, or additional relevant certification.
- Experience with clinical data reconciliation, reporting, and workflow optimization.
Physical Requirements: - This role offers the benefits of a remote-first work environment, supporting work-life balance and flexibility. Employees may occasionally attend in-person training or team events a few times per year.
- Standard postures include standing, sitting, bending, walking, and driving.
- Frequently uses a laptop computer to enter orders and obtain product information.
- Sensory requirements include speech, vision, smell, and hearing.
- Lifting requirements of up to 20 pounds frequently and up to 50 pounds occasionally
- Bloodborne Pathogens Exposure Category III - Employee who rarely has contact with blood and body fluids.
Compensation & Benefits:Competitive Salary [This is an S05/S05a exempt position with a min-max rate of: $90,340.00- $109,028.00 /annually]with:
- Retention bonuses
- 401k with generous Employer match
- Medical, Dental, Vision plans
- Tuition Reimbursement for BSN after 6 months of employment
- Exceptional work/life balance - no rotating shifts, holidays or weekends
- Partially funded HSA
- Employee Recognition Platform
- Paid Time Off, Holidays, and Extended Sick Leave
- Short/Long term Disability
- Employee Assistance Program (EAP)
- Much More!
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