Outpatient Clinical Documentation Improvement (CDI) Specialist

Doctus Data Services Private Limited

Hyderabad

On-site

INR 600,000 - 1,200,000

Full time

14 days+

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Benefits offered by this job

Health insurance

Professional development opportunities

Job summary

A leading company in healthcare seeks an Outpatient Clinical Documentation Improvement (CDI) Specialist to enhance clinical documentation quality, coding accuracy, and regulatory compliance. You will work with a supportive team to improve patient care outcomes and revenue cycle efficiency while ensuring compliance with healthcare standards. Candidates should have a strong background in clinical documentation, outpatient coding, and possess relevant certifications.

Qualifications

Minimum 5 years experience in clinical documentation improvement, medical coding, or outpatient healthcare.
Strong knowledge of outpatient coding methodologies (ICD-10-CM, CPT, HCPCS).
Excellent understanding of clinical terminology and disease processes.

Responsibilities

Conduct reviews of outpatient medical records for accuracy and compliance.
Educate healthcare providers on documentation best practices.
Issue queries to clarify ambiguous documentation.

Skills

Clinical terminology

Analytical skills

Communication

Education

Life Science Graduate or Postgraduate

Tools

EHR systems

CDI software tools

Job description

Outpatient Clinical Documentation Improvement (CDI) Specialist

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Outpatient Clinical Documentation Improvement (CDI) Specialist

Employment Type: Full-Time

Position Summary

The Outpatient Clinical Documentation Improvement (CDI) Specialist is responsible for ensuring the accuracy, completeness, and compliance of clinical documentation in outpatient medical records. This role collaborates with healthcare providers, coding staff, and compliance teams to improve documentation quality, support accurate coding, and ensure appropriate reimbursement while maintaining regulatory compliance. The CDI Specialist plays a critical role in enhancing patient care quality, data integrity, and revenue cycle efficiency in an outpatient setting.

Key Responsibilities

Documentation Review: Conduct concurrent and retrospective reviews of outpatient medical records to ensure documentation accurately reflects the patient’s clinical condition, treatment, and services provided.
Provider Education: Collaborate with physicians, nurse practitioners, and other healthcare providers to educate them on documentation best practices, including specificity and completeness to support accurate coding and billing.
Query Process: Issue compliant, non-leading queries to providers to clarify ambiguous, incomplete, or conflicting documentation, ensuring alignment with ICD-10-CM, CPT, and Outpatient coding guidelines.
Coding Support: Work closely with coding and billing teams to ensure documentation supports appropriate code assignment, risk adjustment, and reimbursement.
Compliance: Ensure documentation meets regulatory requirements, including CMS, HIPAA, and other federal and state guidelines, to minimize audit risks.
Data Analysis: Monitor and analyze documentation trends, identifying opportunities for improvement in clinical documentation processes and provider education.
Quality Improvement: Participate in quality improvement initiatives to enhance patient outcomes, documentation accuracy, and organizational performance metrics.

Qualifications

Education: Life Science Graduate or Postgraduate.

Experience:

Minimum of 5 years of experience in clinical documentation improvement, medical coding, or outpatient healthcare settings.
Strong knowledge of outpatient coding methodologies (ICD-10-CM, CPT, HCPCS) and risk adjustment models.
Certifications (one or more preferred):
Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP).
Certified Professional Coder (CPC) or Certified Coding Specialist (CCS).
Skills:
Excellent understanding of clinical terminology, disease processes, and treatment protocols.
Strong analytical skills to interpret clinical documentation and identify gaps.
Exceptional communication and interpersonal skills to engage with providers and interdisciplinary teams.
Proficiency in EHR systems (e.g., Epic, Cerner) and CDI software tools.
Detail-oriented with a commitment to accuracy and compliance.

Preferred Qualifications

Experience in outpatient or ambulatory care settings, such as clinics, physician practices, or urgent care facilities.
Knowledge of value-based care models and their impact on documentation and reimbursement.
Familiarity with payer-specific documentation requirements (e.g., Medicare Advantage, Medicaid).
Requires the ability to work independently and collaboratively in a fast-paced environment.

Why Join Us? This role offers a unique opportunity to make a meaningful impact on healthcare quality and reimbursement accuracy. Join a collaborative and supportive team committed to excellence in clinical documentation, compliance, and patient outcomes at Doctus.