Outpatient Clinical Documentation Improvement

Job Description: Outpatient Clinical Documentation Improvement (CDI) Specialist:

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 to identify 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: 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.

Take the Next Step in Your CDI Career: Apply now and play a key role in shaping the future of clinical documentation integrity

How to Apply

Please submit a resume and cover letter to . Please include "Outpatient CDI Specialist Application " in the subject line.