Clinical Documentation Specialist

University of Arkansas for Medical Sciences • Little Rock, AR

1d

About The Position

The Clinical Documentation Specialist supports University of Arkansas for Medical Sciences UAMS population health, quality, and financial performance through accurate, complete, and compliant risk-adjusted coding. This position is responsible for conducting comprehensive coding audits, identifying documentation and coding improvement opportunities, and ensuring compliance with CMS and payer guidelines. A central component of this role is provider education — partnering with clinicians and care teams to enhance understanding of risk adjustment principles, improve documentation practices, and strengthen audit readiness. The specialist combines coding expertise, analytical skills, and educational engagement to drive accurate diagnosis capture and optimal risk adjustment outcomes across all value-based care contracts.

Requirements

• Registered Nurse (RN) with current license plus 4 years inpatient clinical experience in Emergency, Critical Care, or Medical/Surgical area with experience in Quality, Case Management, Clinical Audit, or Data Abstraction - OR - Coding professional with CCS certification and 6 years of inpatient coding experience with documented education in anatomy/physiology and pharmacology.
• Must have excellent written and verbal communication skills.
• Experience in auditing and clinical documentation review within an ACO, health plan, or value-based care environment.
• Strong knowledge of ICD-10-CM, HCC models, and CMS risk adjustment guidelines
• Detail oriented, with ability to work as part of a team and independently.
• Knowledge of clinical quality measures and evaluation.

Nice To Haves

• Certified Professional Coder (CPC)
• Certified Risk Adjustment Coder (CRC) –Coding Specialist (CCS) or Clinical Documentation Improvement (CDI) Certification
• 2 years work in Risk Coding, provider education, audit experience in a billing coding role

Responsibilities

• Perform detailed retrospective and prospective reviews of provider documentation to ensure accurate assignment of ICD-10-CM codes that support risk adjustment models (CMS-HCC, HHS-HCC, etc.).
• Validate that diagnoses meet all MEAT (Monitored, Evaluated, Assessed, Treated) criteria and align with official coding guidelines.
• Develop prospective process for pre-visit charting prioritizing high risk patient cohorts.
• Identify and correct coding discrepancies or missed opportunities that impact risk scores and quality metrics.
• Partner with physicians, Advanced Practice Providers, and care teams to provide feedback and education on documentation best practices and accurate coding.
• Develop and deliver training sessions, workshops, or provider tip sheets focused on risk adjustment principles, MEAT criteria, and condition specificity.
• Serve as a subject matter expert on coding and documentation policy updates, ensuring provider network awareness and compliance.
• Promote a culture of documentation excellence through ongoing education and collaboration.
• Collaborate with the population health teams to track coding completeness, identify trends, and prioritize high-impact patient cohorts.
• Use data-driven insights to support Value Based Care initiatives such as gap closure, RAF optimization, and quality measure improvement.
• Prepare detailed audit reports and participate in audit follow-up activities, including root-cause analysis and education.
• Collaborate with billing and revenue cycle teams to ensure appropriate claim corrections or adjustments are made, without directly altering billing or claim data.
• Maintain current knowledge of risk adjustment regulations, coding policies, and payer-specific documentation requirements.
• Other duties as assigned.

Benefits

• Medical, Dental and Vision plans available for qualifying staff and family
• Holiday, Vacation and Sick Leave
• Education discount for staff and dependents (undergraduate only)
• Up to 10% matched contribution from UAMS
• Basic Life Insurance up to $50,000
• Career Training and Educational Opportunities
• Merchant Discounts
• Concierge prescription delivery on the main campus when using UAMS pharmacy

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed
• Number of Employees: 5,001-10,000 employees