Clinical Documentation Integrity

Orcapod Consulting Services; Hyderabad; On-site; INR 600,000 - 900,000; Full time

Job summary

Orcapod Consulting Services invites a CDI Specialist to join our clinical documentation team in Hyderabad. You will review and optimize documentation to improve accuracy, completeness, and compliant reimbursement, working with physicians and care teams to ensure high-quality records.

The role requires 1+ year CDI/Health Information Management experience, nursing or life sciences background, and familiarity with ICD-10-CM/PCS, APR-DRG, CMS guidelines, and EHR systems.

Qualifications

• Clinical Documentation Integrity (CDI) experience or Health Information Management
• Understanding of ICD-10-CM/PCS coding and reimbursement
• Ability to collaborate with physicians to query and improve documentation

Responsibilities

• Review clinical documentation for completeness and accuracy
• Identify documentation gaps and improvement opportunities
• Conduct retrospective reviews for Mortality, HAC, and PSI cases
• Collaborate with physicians to improve documentation quality
• Support accurate capture of Severity of Illness (SOI) and Risk of Mortality (ROM)
• Ensure compliance with documentation and regulatory standards
• Participate in documentation quality improvement initiatives

Skills

ICD-10-CM/PCS knowledge

Anatomy, Physiology, Pathophysiology

CMS Guidelines & APR-DRG

EHR Systems proficiency

Physician query management

Analytical thinking

Communication skills

Education

B.Sc. Nursing / M.Sc. Nursing

B.Pharm / M.Pharm

Life Sciences Graduate or Postgraduate

Tools

CDI Tools

EHR Systems

Job description

Hiring: Specialist (CDI)

Location: Hyderabad, Telangana
Employment Type: Full-Time / Permanent
Experience Required: 13 Years

Job Summary

We are looking for a skilled and detail-oriented Clinical Documentation Integrity (CDI) Specialist responsible for reviewing and improving the accuracy, completeness, and quality of clinical documentation within patient medical records. The role focuses on ensuring appropriate clinical representation, quality outcomes, and accurate reimbursement through effective documentation practices.

Eligibility Criteria

Educational Qualification

• B.Sc. Nursing / M.Sc. Nursing
• B.Pharm / M.Pharm
• Life Sciences Graduate or Postgraduate

Preferred Certifications (Mandatory or Highly Preferred)

• CDIP (Certified Documentation Integrity Practitioner)
• CDEI (Certified Documentation Expert Inpatient)
• CCDS / CCDS-O (Certified Clinical Documentation Specialist)

Experience

• Minimum 1+ year of experience in Clinical Documentation Improvement (CDI), Clinical Documentation Review, or Health Information Management.

Required Skills

• Strong understanding of Anatomy, Physiology, Pathophysiology, and Pharmacology
• Knowledge of ICD-10-CM/PCS Coding
• Understanding of APR-DRG, MS-DRG, and CMS Guidelines
• Medical Record Review and Clinical Documentation Analysis
• Physician Query Management and Provider Education
• Experience with EHR Systems and CDI Tools
• Excellent Verbal and Written Communication Skills
• Strong Analytical and Critical Thinking Ability
• Attention to Detail and Documentation Accuracy

Key Responsibilities

• Review clinical documentation for completeness, accuracy, and specificity.
• Identify documentation gaps and improvement opportunities.
• Conduct retrospective reviews for Mortality, HAC, and PSI cases.
• Collaborate with physicians and healthcare providers to improve documentation quality.
• Support accurate capture of Severity of Illness (SOI) and Risk of Mortality (ROM).
• Ensure compliance with documentation and regulatory standards.
• Participate in documentation quality improvement initiatives.

Preferred Candidate Profile

• Certified CDI Professional with relevant healthcare documentation experience.
• Strong understanding of healthcare reimbursement and quality metrics.
• Ability to work independently in a fast-paced environment.
• Excellent organizational and problem-solving skills.

Experience: 13 Years
Job Type: Full-Time
Work Location: Hyderabad

9685741994

[e-mail]