PHO RN Risk Adjustment CDI Specialist

Overview

The PHO RN Risk Adjustment CDI Specialist supports accurate, complete, and compliant clinical documentation to ensure appropriate risk adjustment capture and high-quality patient records. This role works closely with providers, coders, and analytics teams to improve documentation specificity, HCC capture, and CMS compliance - primarily within Medicare Advantage populations as well as the Symmetry Risk Engine (SRE) for the commercial population. The RN Risk Adjustment CDI specialist serves as a clinical bridge between providers and coding, translating regulatory requirements into practical, provider-friendly guidance. Demonstrates excellent customer service performance in attitude and actions that are at all times consistent with the standards contained in the Vision, Mission and Values of Covenant Healthcare and the commitment to Extraordinary Care for Every Generation.

Responsibilities

• Perform concurrent, prospective, and retrospective chart reviews for clinical documentation improvement.
• Identify documentation gaps related to HCCs, MEAT criteria, and chronic condition specificity.
• Ensure diagnoses are clinically supported, clearly documented, and compliant.
• Collaborate with coding staff to resolve documentation discrepancies.
• Educate physicians and APPs on HCC documentation standards, annual condition confirmation, and CMS and payer risk adjustment requirements.
• Provide individualized provider feedback and practice-level education.
• Support optimization of Annual Wellness Visits (AWVs) and chronic care visits.
• Assist in validating suspect condition lists.
• Support RAF performance improvement initiatives.
• Participate in provider scorecards and performance reviews.
• Perform reporting and partner with analysts to understand documentation trends and opportunities.
• Support preparation for RADV, payer, and internal audits.
• Ensure documentation meets CMS and payer standards.
• Assist with audit responses and documentation validation.
• Work closely with Coders, Quality improvement, Care management and Population health teams and departments.
• Contribute to workflow improvements and best practices.
• Participate in policy and procedure development.
• Fosters a team approach and includes patient/family as active members of the team.
• Participate in required continuing education opportunities.

Qualifications

EDUCATION/EXPERIENCE

• Bachelor’s degree in nursing required. In lieu of bachelor’s degree in nursing, a candidate with two (2) years nursing experience and demonstrated leadership, who is committed and willing to obtain a bachelor’s degree in nursing within five (5) years upon hire in position will be considered.
• Must have a current Registered Nurse (RN) license to practice in the State of Michigan.
• Minimum three (3) years of clinical experience required, with primary care, internal medicine, or chronic disease management setting within the past five (5) years preferred.
• Experience in Medicare Advantage risk adjustment, CDI, coding, quality, or utilization management, and EHRs (Epic, eClinicalWorks, Athena, etc.) preferred.

KNOWLEDGE/SKILLS/ABILITIES

• Strong knowledge of clinical documentation standards, chronic disease management, and provider workflows.
• Basic knowledge of CMS-HCC models.
• Commitment to ethical practice of social work principles (patient self-determination, privacy, dignity, cultural sensitivity).
• Knowledge of behavioral health conditions, evidence-based guidelines, mental health risk assessment, and patient education preferred.
• Ability to manage complex mental health issues utilizing assessment skills and protocols.
• Excellent assessment, triage and critical thinking skills.
• Ability to implement evidence base interventions and protocols for mental health conditions.
• Ability to travel to work in the physician offices, attend meetings and conferences as needed.
• Demonstrates customer focused interpersonal skills, and the ability with the understanding of cultural diversity to interact in an effective manner with practitioners, patients, and families.
• Demonstrates ability to work autonomously and be directly accountable for practice.
• Excellent computer knowledge and capability to use computer; i.e. Microsoft Word, Excel. Epic experience preferred.
• Demonstrates ability to develop positive, longitudinal relationships and set appropriate boundaries with patients/families.

WORKING CONDITIONS/ PHYSICAL DEMANDS

• Ability to maintain regular, punctual attendance consistent with the ADA, FMLA and other federal, state and local standards.
• Constant Sitting, near vison, finger dexterity, talking, hearing, tasting/smelling.
• Frequent Depth perception.
• Frequent lifting up to 10 lbs.
• Occasional Standing, walking, lifting/carrying, pushing/pulling, stooping, kneeling,

crouching, squatting, crawling, far vision.

• Occasional lifting up to 50 lbs.