Doctus Data Services Private Limited | Inpatient Clinical Documentation Integrity
6 days ago
About the Role:
We are seeking a seasoned and detail-oriented Inpatient CDI Specialist to join our team. This role is crucial in improving the accuracy of clinical documentation and aligning it with inpatient coding standards. The position emphasizes enhancing data quality, ensuring proper risk adjustment, and maintaining compliance to support organizational quality and financial objectives.
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Key Responsibilities
Clinical Documentation and Coding Accuracy:
· Conduct comprehensive reviews of inpatient medical records to validate clinical documentation and ensure ICD-10-CM/PCS coding accuracy.
· Collaborate with providers to ensure documentation supports accurate DRG assignments, SOI, ROM, as well as CCs and MCCs.
· Address documentation gaps, inconsistencies, and areas requiring clarification through focused queries.
· Analyze coding data to identify discrepancies, trends, and areas for improvement.
· Ensure diagnoses critical for mortality and other risk models are documented as "POA.”
Subject Matter Expertise:
· Serve as a key resource for inpatient coding, DRG assignments, and SOI assessments.
· Work closely with coding teams to resolve discrepancies and enhance coding accuracy.
Collaboration and Education:
· Build strong partnerships with physicians, CDI specialists, and clinical teams to bridge documentation gaps.
· Provide targeted education and training on documentation standards, compliance, and best practices.
· Facilitate training sessions to enhance understanding of CDI processes and their impact on quality metrics and reimbursement.
· Function as a liaison between clinical teams, coders, and revenue cycle management.
Compliance and Auditing:
· Ensure all documentation adheres to regulatory standards, including CMS, Joint Commission, and other compliance requirements.
· Participate in audits, evaluate findings, and recommend corrective actions, as needed.
· Support organizational quality initiatives and contribute to performance improvement projects.
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Qualifications and Skills
Required Credentials and Experience:
· Certifications: CDIP, CCDS, or CCS.
· Experience: At least 7 years in US healthcare with a focus on inpatient coding, CDI processes, or data quality audits, demonstrating strong expertise in ICD-10-CM/PCS coding and DRG assignments.
· Advanced knowledge of US healthcare reimbursement methodologies, including MS-DRG and APR-DRG.
· Familiarity with payer-specific policies, official coding guidelines, and regulatory standards (e.g., CMS, AHIMA).
· Proficiency in EHR systems (e.g., Epic, Oracle-Cerner) and coding tools (e.g., 3M, Nuance, Optum).
Desired Skills:
· Exceptional analytical skills to identify trends and resolve discrepancies in documentation and coding.
· Outstanding interpersonal and communication abilities to foster collaboration and provide education.
· Proven track record of delivering effective training sessions and analyzing CDI metrics such as query response rates and documentation improvements.
· Up-to-date knowledge of regulatory changes and industry best practices in CDI.
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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.
Take the Next Step in Your CDI Career: Apply now and play a key role in shaping the future of clinical documentation integrity
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Hyderabad, Telangana, India Doctus Data Services Private Limited Full timeWe are seeking a seasoned and detail-oriented Inpatient CDI Specialist to join our team at Doctus Data Services Private Limited.This role is crucial in improving the accuracy of clinical documentation and aligning it with inpatient coding standards.The position emphasizes enhancing data quality, ensuring proper risk adjustment, and maintaining compliance to...
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Hyderabad, Telangana, India Doctus Data Services Private Limited Full timeAs a seasoned Inpatient Clinical Documentation Integrity Specialist, you will play a pivotal role in enhancing data quality and ensuring compliance with regulatory standards at Doctus Data Services Private Limited.Key Responsibilities:Conduct comprehensive reviews of inpatient medical records to validate clinical documentation and ensure ICD-10-CM/PCS coding...
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