Clinical Documentation Improvement Specialist

Role Overview

We are looking for a skilled Clinical Documentation Improvement (CDI) Specialist on a contract basis to ensure the precision, clinical validation, and quality of patient medical records. This position involves evaluating the completeness and accuracy of clinical documents and working closely with healthcare providers to address any documentation gaps.

Key Responsibilities

• Examine clinical documents to verify accuracy, completeness, and compliance with guidelines.
• Detect deficiencies in documentation and facilitate clarification by engaging with providers through queries.
• Conduct both concurrent and retrospective reviews of patient charts.
• Ensure correct representation of severity of illness and risk of mortality in records.
• Work collaboratively with physicians, coders, and clinical teams to enhance documentation standards.

Qualifications and Experience

• Licensed Registered Nurse (RN) or Physician (MD/MBBS) background required.
• Proven experience in Clinical Documentation Improvement roles.
• In-depth knowledge of clinical documentation and coding systems such as ICD-10 and DRG.
• Self-motivated with strong communication skills for effective provider interaction.

Preferred Skills

• Experience with outpatient, ambulatory care, or risk adjustment (HCC) documentation is advantageous.
• Possession of certifications like CDIP, CCDS, or CRC is desirable.
• Familiarity with Epic or similar electronic health record platforms is a plus.

Additional Details

• Duration of the contract is approximately six to seven months.
• The position is remote following an initial onboarding period.
• Work schedule aligns with standard business hours.