CDI - Outpatient EM Specialist

Sutherland; Hyderabad; On-site; INR 1,200,000 - 1,800,000; Full time

Job summary

Sutherland is seeking a Clinical Documentation Integrity (CDI) E/M Outpatient specialist in Hyderabad to review outpatient records, ensure documentation supports E/M levels, and identify gaps. You will collaborate with physicians, coders, and auditors to improve coding accuracy and compliance.

The role requires strong knowledge of outpatient E/M coding, CPT/ICD-10-CM/HCPCS, and medical necessity, with an emphasis on accuracy, communication, and professional documentation improvement

Qualifications

• Strong knowledge of Outpatient E/M coding and documentation guidelines
• Proficient in CPT, ICD-10-CM, HCPCS and medical terminology
• Strong understanding of E/M Medical Decision Making (MDM)
• Ability to interpret physician documentation and correlate diagnoses with clinical information
• Knowledge of medical necessity and documentation compliance
• Strong analytical and critical-thinking skills
• Excellent written and verbal communication skills
• Ability to communicate documentation opportunities professionally with providers and internal stakeholders
• Strong attention to detail and commitment to documentation accuracy

Responsibilities

• Review outpatient medical records for accuracy, completeness, specificity, and clinical consistency
• Validate documentation to support appropriate E/M code selection and level of service
• Evaluate E/M services based on MDM and/or time, as applicable
• Review documentation related to problems addressed and their complexity, data reviewed, risk, and total time
• Identify documentation gaps, inconsistencies, and conflicting information
• Prepare compliant provider queries and clarification requests
• Ensure documentation supports reported diagnoses, procedures, medical necessity, and services
• Review outpatient E/M encounters including office visits, clinic services, ED, preventive services and other professional services
• Collaborate with physicians, coders, auditors, and operational teams to improve documentation and coding accuracy
• Provide education and feedback on documentation improvement opportunities
• Identify recurring trends and recommend corrective actions
• Support audits and assist with documentation-related findings
• Maintain quality, productivity and turnaround-time standards
• Maintain patient confidentiality and compliance with privacy and security requirements

Skills

Outpatient E/M coding

CPT/ICD-10-CM/HCPCS

E/M MDM

Physician documentation interpretation

Medical necessity & compliance

Attention to detail

Communication skills

Job description

We are looking for a Clinical Documentation Integrity (CDI) E/M Outpatient (EM OP) professional with strong knowledge of outpatient E/M coding, clinical documentation, and medical necessity.

The role involves reviewing outpatient medical records, identifying documentation gaps, and ensuring that clinical documentation accurately supports the services, diagnoses, and E/M level reported.

Interview Process:

• Personal Information
• Screening Question
• Video Interview

Key Responsibilities

• Review outpatient medical records for accuracy, completeness, specificity, and clinical consistency.
• Validate documentation to support appropriate E/M code selection and level of service.
• Evaluate E/M services based on Medical Decision Making (MDM) and/or time, as applicable.
• Review documentation related to:
• Problems addressed and their complexity
• Data reviewed and analyzed
• Risk of patient management
• Total time documentation, when applicable
• Identify documentation gaps, inconsistencies, and conflicting information.
• Prepare compliant provider queries and clarification requests when additional documentation is required.
• Ensure documentation supports reported diagnoses, procedures, medical necessity, and services provided.
• Review various outpatient E/M encounters, including office visits, outpatient/clinic services, emergency department services, preventive services, and other applicable professional services.
• Collaborate with physicians, coders, auditors, and operational teams to improve documentation and coding accuracy.
• Provide education and feedback on documentation improvement opportunities.
• Identify recurring documentation and coding trends and recommend appropriate corrective actions.
• Support internal and external audits and assist with documentation-related findings.
• Maintain required quality, productivity, and turnaround-time standards.
• Maintain patient confidentiality and comply with all applicable privacy, security, and compliance requirements.

Required Skills & Knowledge

• Strong knowledge of Outpatient E/M coding and documentation guidelines.
• Good understanding of CPT, ICD-10-CM, HCPCS, and medical terminology.
• Strong understanding of E/M Medical Decision Making (MDM).
• Ability to interpret physician documentation and correlate diagnoses with clinical information.
• Knowledge of medical necessity and documentation compliance.
• Strong analytical and critical-thinking skills.
• Excellent written and verbal communication skills.
• Ability to communicate documentation opportunities professionally with providers and internal stakeholders.
• Strong attention to detail and commitment to documentation accuracy.