About the Role
We are looking for an experienced Clinical Documentation Improvement (CDI) Specialist to ensure the accuracy, completeness, and integrity of clinical documentation for US healthcare clients. The ideal candidate will collaborate with physicians and coding teams to improve documentation quality, support accurate coding and reimbursement, and ensure compliance with industry standards.
Key Responsibilities
- Review inpatient and/or outpatient medical records to identify documentation improvement opportunities.
- Evaluate clinical documentation, laboratory results, diagnostic findings, and treatment plans to support accurate code assignment.
- Query physicians for missing, conflicting, or incomplete documentation using compliant CDI practices.
- Collaborate with coding and clinical teams to improve documentation accuracy and support appropriate MS-DRG and APR-DRG assignment.
- Educate providers on documentation best practices, severity of illness (SOI), risk of mortality (ROM), and coding guidelines.
- Verify the completeness and accuracy of patient medical records.
- Analyze documentation trends and recommend process improvements.
- Maintain compliance with client standards, HIPAA, and applicable CDI guidelines.
Qualifications
- Bachelor's degree in Nursing or any Allied Health program.
- Active Philippine RN license or an active medical coding certification (CCDS, CDIP, CCS, CIC, CPC, or CRCR).
- Minimum of 3–5 years of Clinical Documentation Improvement (CDI) experience.
- At least 3–5 years of clinical or hospital experience.
- Experience with inpatient concurrent CDI reviews.
- Strong knowledge of ICD-10-CM/PCS, MS-DRG, and APR-DRG methodologies.
- Excellent understanding of medical terminology, disease processes, and clinical documentation standards.
- Strong analytical, communication, and critical thinking skills.
