Clinical Quality & Documentation Improvement Specialist (RN/LPN)
Access Health Care is seeking an experienced Clinical Quality & Documentation Improvement Specialist to join our growing Quality Department. This role is ideal for a clinically licensed professional who is passionate about quality improvement, value-based care, population health, risk adjustment, and provider education.
The ideal candidate will have a strong clinical background and experience with NCQA, CMS, HEDIS, 5-Star, ACO, Risk Adjustment, and Clinical Documentation Improvement (CDI) initiatives.
Position Summary
The Clinical Quality & Documentation Improvement Specialist is responsible for monitoring, auditing, and improving clinical documentation, coding accuracy, quality outcomes, utilization management, and regulatory compliance. This position partners closely with providers and office staff to support quality measures, close care gaps, improve patient outcomes, and optimize organizational performance.
Essential Responsibilities
- Monitor and audit medical record documentation for compliance with NCQA and CMS specifications.
- Support and lead initiatives related to HEDIS, CMS Star Ratings, ACO measures, and value-based care programs.
- Work quality gap reports and assist with closure of care gaps for 5-Star, HEDIS, and ACO quality measures.
- Conduct clinical documentation and coding audits to ensure compliance with ICD-10, CPT, CMS, and payer guidelines.
- Educate providers and staff on documentation improvement, coding compliance, and quality measure requirements.
- Assist with Medicare Risk Adjustment and chronic condition management initiatives.
- Analyze quality and utilization data to identify opportunities for improvement.
- Collaborate with Care Management, Case Management, providers, and leadership to improve patient outcomes.
- Support quality improvement projects, audits, and regulatory compliance activities.
- Review and validate quality measure data within EMR and reporting systems.
- Serve as a subject matter expert for quality, compliance, documentation improvement, and coding initiatives.
Required Qualifications
- Current Florida RN or LPN License.
- Minimum of three (3) years of clinical healthcare experience.
- Minimum of two (2) years of experience in one or more of the following:
- Quality Management
- HEDIS
- Medicare Advantage
- Risk Adjustment
- Clinical Documentation Improvement (CDI)
- Utilization Management
- Population Health
- Care Management
- Medical Coding Compliance
Required Knowledge
Candidates must possess working knowledge of:
- NCQA Standards
- CMS Guidelines
- HEDIS Measures
- CMS 5-Star Programs
- ACO Quality Measures
- Medicare Advantage Programs
- Risk Adjustment Methodology
- Clinical Documentation Improvement Practices
- ICD-10 and CPT Coding Guidelines
Required Skills
- Ability to review and analyze medical records.
- Strong clinical assessment and critical thinking skills.
- Excellent verbal and written communication skills.
- Strong organizational and time-management abilities.
- Ability to educate and engage providers and clinical staff.
- Proficiency with EMR/EHR systems and Microsoft Office applications.
- Ability to travel between assigned practice locations as needed.
Preferred Certifications
One or more of the following certifications is preferred:
- CPC (Certified Professional Coder)
- CRC (Certified Risk Adjustment Coder)
- CCDS (Certified Clinical Documentation Specialist)
- CDIP (Certified Documentation Improvement Practitioner)
- CPHQ (Certified Professional in Healthcare Quality)
- CCM (Certified Case Manager)
Candidates without certification must be willing to obtain a CPC, CRC, CCDS, or CDIP certification within 12 months of hire.
Why Join Access Health Care?
- Competitive salary
- Comprehensive benefits package
- Professional growth and development opportunities
- Collaborative team environment
- Meaningful impact on patient outcomes and quality performance
- Opportunity to work in a value-based care organization focused on excellence
Job Type: Full-Time
License Required: Active Florida RN or LPN License
Preferred Experience: HEDIS, Medicare Advantage, Quality Improvement, Risk Adjustment, Clinical Documentation Improvement, Population Health, and Provider Education.
Experience Level: Mid-Level to Senior Clinical Quality Professional
Work Location: Travel between assigned practice locations as needed.
Pay: From $20.00 per hour
Benefits:
- 401(k)
- 401(k) matching
- AD&D insurance
- Dental insurance
- Employee assistance program
- Flexible spending account
- Health insurance
- Health savings account
- Life insurance
- Paid time off
- Parental leave
- Prescription drug insurance
- Referral program
- Retirement plan
- Vision insurance
Experience:
- HEDIS: 1 year (Required)
- NCQA standards: 1 year (Required)
- Medicare stars: 1 year (Required)
- Risk management: 1 year (Preferred)
- Clinical documentation: 1 year (Required)
License/Certification:
- LPN (Preferred)
- RN License (Preferred)
Work Location: In person
