Clinical Documentation Integrity (CDI) specialist

HealthRecon Connect; Lanka; Hybrid; INR 900,000 - 1,200,000; Full time

Job summary

HealthRecon Connect seeks a Clinical Documentation Integrity (CDI) specialist to join our team. Perform comprehensive CDI work for physician, ambulatory, and outpatient documentation to ensure completeness and regulatory compliance.

You will review notes for clarity, identify documentation gaps, validate diagnoses and procedures, and audit encounter-level coding with ICD-10-CM, CPT, and HCPCS. This is a hybrid role with a US calendar and potential on-site five days per week.

Qualifications

• Minimum 5 years of medical coding experience (physician/ambulatory preferred).
• Minimum 2-3 years of CDI audit experience or mixed coding Audit and CDI (minimum 1.5-2 years in CDI exclusively).
• Strong knowledge of ICD-10-CM, CPT®, HCPCS, EM guidelines, and payer policies.
• Proven ability to review and evaluate physician documentation for completeness and specificity.

Responsibilities

• Clinical Documentation Integrity (CDI) specialist Perform comprehensive CDI works for physician, ambulatory, and outpatient documentation.
• Review provides notes for completeness, clarity, specificity, medical necessity, and compliance with regulatory standards.
• Identify documentation gaps, missed diagnoses, unspecified conditions, and conflicting or ambiguous documentation.
• Validate that clinical documentation supports reported diagnoses and procedures.
• Track and report audit findings, provider education outcomes, and documentation trends.
• Clinical Documentation Integrity (CDI) Auditing Perform comprehensive CDI audits for physician, ambulatory, and outpatient documentation.
• Review provides notes for completeness, clarity, specificity, medical necessity, and compliance with regulatory standards.
• Identify documentation gaps, missed diagnoses, unspecified conditions, and conflicting or ambiguous documentation.
• Validate that clinical documentation supports reported diagnoses and procedures.
• Track and report audit findings, provider education outcomes, and documentation trends.
• Validate EM levels, procedure coding, modifiers, and medical necessity coverage guidelines.
• Audit encounter-level coding to ensure correct code selection and support clean claim submission.
• Assign accurate and compliant ICD-10-CM, CPT, and HCPCS codes based on provider documentation.
• Proven ability to review and evaluate physician documentation for completeness and specificity.
• Excellent written communication skills for provider feedback reports.
• Ensure adherence to CMS guidelines, NCCI edits, payer policies, and audit methodologies.
• Maintain >96% coding accuracy and >98% audit accuracy.
• Support internal compliance initiatives and contribute to ongoing CDI improvement projects.
• Certification: CCDS. CDEO, CDIP, CPHQ, CCS OR CPC (last to be looked for) certification.

Skills

Medical coding

CDI auditing

Documentation review

CMS guidelines knowledge

EMR/EHR familiarity

Tools

Athena

Epic

Cerner

eClinicalWorks

Job description

HealthRecon Connect provides technology-enabled Revenue Cycle Management solutions to US healthcare providers. The company leverages over 30 years of deep domain expertise, machine learning, AI, cutting-edge analytics, and automated workflows that help improve cash flow, patient outcomes and enable peace of mind for their clients. At HealthRecon Connect, day after day, we not only hold ourselves accountable for setting and maintaining high standards, but we also passionately strive for the highest achievement, customer delight and thrive on the challenge of high expectations and commitment to excel.

HealthRecon was certified a Great Workplace by Great Place to Work® Sri Lanka since 2018 and was adjudged one of the 40 Best Workplaces in Sri Lanka by Great Place to Work® Sri Lanka in 2021. We are also a participant of the United Nations Global Compact.

We are looking for a Clinical Documentation Integrity (CDI) specialist to join our team. Please review the criteria and other information listed below thoroughly prior to applying and pay specific attention to the work week, shift details and other features of the job.

Due to the large volume of applications we receive, all applications will be reviewed in the order in which they were received and only the candidates short-listed for the first round of interviews will be contacted. Thank you for your understanding.

Job Vacancy:

Clinical Documentation Integrity (CDI) specialist

Work Week:

Monday to Friday

Shift Window:

2:00 PM to 11:00 PM IST (Straddle Shift)

Important: HealthRecon Connect currently operates under a hybrid work arrangement, with the number of remote workdays varying by team. However, depending on client deliverables and business needs, employees may be required to work on-site for all five weekdays.

By applying, you acknowledge and agree to be available for in-person work five days a weekifrequired.

Other Features:

• Full-time
• US calendar applicable

Responsibilities:

• Clinical Documentation Integrity (CDI) specialist Perform comprehensive CDI works for physician, ambulatory, and outpatient documentation.
• Review provides notes for completeness, clarity, specificity, medical necessity, and compliance with regulatory standards.
• Identify documentation gaps, missed diagnoses, unspecified conditions, and conflicting or ambiguous documentation.
• Validate that clinical documentation supports reported diagnoses and procedures.
• Track and report audit findings, provider education outcomes, and documentation trends.
• Clinical Documentation Integrity (CDI) Auditing Perform comprehensive CDI audits for physician, ambulatory, and outpatient documentation.
• Review provides notes for completeness, clarity, specificity, medical necessity, and compliance with regulatory standards.
• Identify documentation gaps, missed diagnoses, unspecified conditions, and conflicting or ambiguous documentation.
• Validate that clinical documentation supports reported diagnoses and procedures.
• Track and report audit findings, provider education outcomes, and documentation trends.
• Validate EM levels, procedure coding, modifiers, and medical necessity coverage guidelines.
• Audit encounter-level coding to ensure correct code selection and support clean claim submission.
• Assign accurate and compliant ICD-10-CM, CPT, and HCPCS codes based on provider documentation.
• Proven ability to review and evaluate physician documentation for completeness and specificity.
• Excellent written communication skills for provider feedback reports.
• Ensure adherence to CMS guidelines, NCCI edits, payer policies, and audit methodologies.
• Maintain >96% coding accuracy and >98% audit accuracy.
• Support internal compliance initiatives and contribute to ongoing CDI improvement projects.
• Certification: CCDS. CDEO, CDIP, CPHQ, CCS OR CPC (last to be looked for) certification.

Qualifications/Criteria:

• Minimum 5 years of medical coding experience (physician/ambulatory preferred).
• Minimum 2-3 years of CDI audit experience or mixed coding Audit and CDI (minimum 1.5-2 years in CDI exclusively).
• Strong knowledge of ICD-10-CM, CPT®, HCPCS, EM guidelines, and payer policies.
• Proven ability to review and evaluate physician documentation for completeness and specificity.
• Experience with specialties such as Internal Medicine, Family Medicine, Orthopaedics, Cardiology, Surgery, or Rehab.
• Exposure to EMR/EHR systems (Athena, Epic, Cerner, eClinicalWorks, etc.).