Healthcare Documentation Specialist

1 day ago

Hyderabad, Telangana, India beBeeClinical Full time ₹ 1,00,00,000 - ₹ 1,50,00,000
Job Title:

Clinical Documentation Improvement Specialist

Description:

As a Clinical Documentation Improvement Specialist, you will play a crucial role in enhancing the accuracy and completeness of medical records. This position requires expertise in clinical documentation requirements, coding guidelines, and regulatory standards.

Key Responsibilities:
  • Medical Record Review:
    • Conduct concurrent and retrospective reviews of inpatient and outpatient medical records to identify opportunities for documentation improvement.
    • Evaluate the accuracy and completeness of clinical documentation to ensure it reflects the patient's condition, treatment, and outcomes.
    • Identify discrepancies, inconsistencies, and missing information in the medical record.
    • Analyze documentation to determine the principal diagnosis, comorbidities, and complications.
  • Physician Collaboration and Education:
    • Communicate with physicians and other healthcare providers to clarify documentation and obtain additional information.
    • Provide education and training to physicians and other healthcare providers on documentation requirements, coding guidelines, and regulatory standards.
    • Conduct one-on-one education sessions with physicians to address specific documentation deficiencies.
    • Develop and deliver educational materials, presentations, and workshops on CDI topics.
  • Coding and Reimbursement:
    • Ensure that documentation supports accurate coding and billing practices.
    • Collaborate with coding staff to resolve coding discrepancies and documentation issues.
    • Understand the impact of documentation on reimbursement and DRG (Diagnosis Related Group) assignment.
    • Stay current on changes in coding guidelines (ICD-10, CPT, HCPCS) and reimbursement policies.
  • Data Analysis and Reporting:
    • Collect and analyze data related to CDI activities, including query rates, physician response rates, and documentation improvement metrics.
    • Prepare reports and presentations on CDI performance and trends. Identify opportunities to improve CDI processes and outcomes.
    • Participate in quality improvement initiatives and performance improvement projects.
  • Regulatory Compliance:
    • Ensure compliance with all applicable regulatory requirements, including HIPAA, CMS (Centers for Medicare & Medicaid Services), and Joint Commission standards.
    • Stay current on changes in regulatory requirements and guidelines related to clinical documentation and coding.
    • Participate in internal audits and external reviews of clinical documentation.
  • Team Leadership and Mentorship:
    • Serve as a mentor and resource for junior CDI Specialists.
    • Provide guidance and support to the CDI team on complex cases and documentation challenges.
    • Assist in training new team members on CDI processes and procedures.
    • Participate in team meetings and contribute to the development of CDI strategies.
  • System Proficiency:
    • Utilize electronic health record (EHR) systems and CDI software to manage medical record reviews and documentation queries.
    • Maintain accurate and up-to-date information in CDI tracking systems.

  • Healthcare Documentation Specialist

    4 days ago

    Hyderabad, Telangana, India beBeeClinical Full time ₹ 2,00,00,000 - ₹ 2,50,00,000

    Thryve Digital Health LLP, an emerging global healthcare partner, delivers strategic innovation and flexibility to its healthcare partners. A US healthcare conglomerate captive, they have direct access to deeper insights that accelerate their learning process and keep them ahead of the curve.Their global collaborative of healthcare, operations, and IT...

  • Healthcare Professional

    16 hours ago

    Hyderabad, Telangana, India beBeeClinicalDocumentation Full time ₹ 30,00,000 - ₹ 42,00,000

    Unlock your career potential as a skilled healthcare professional with this exciting opportunity!We are seeking a highly motivated and detail-oriented individual to join our team as a Clinical Documentation Improvement Specialist.In this role, you will be responsible for conducting concurrent and retrospective reviews of medical records to identify areas for...

  • Clinical Documentation Improvement Specialist

    4 weeks ago

    Hyderabad, Telangana, India Thryve Digital Health LLP Full time

    Thryve Digital Health LLP is an emerging global healthcare partner that delivers strategic innovation, expertise, and flexibility to its healthcare partners.Being a US healthcare conglomerate captive, we have direct access to deeper insights that help us accelerate our learning process and keeps us ahead of the curve.Thryve delivers next-generation...

  • Healthcare Credentialing Specialist

    1 day ago

    Hyderabad, Telangana, India beBeeCredentialing Full time ₹ 50,00,000 - ₹ 80,00,000

    Healthcare Credentialing SpecialistAn exciting opportunity to work in healthcare credentialing!As a Healthcare Credentialing Specialist, you will be responsible for managing all aspects of healthcare credentialing and supporting the smooth onboarding of healthcare professionals. This role is vital to ensuring efficient service delivery through accurate...

  • Clinical Documentation Improvement Specialist

    4 weeks ago

    Hyderabad, Telangana, India Thryve Digital Health LLP Full time

    Thryve Digital Health LLP is an emerging global healthcare partner that delivers strategic innovation, expertise, and flexibility to its healthcare partners. Being a US healthcare conglomerate captive, we have direct access to deeper insights that help us accelerate our learning process and keeps us ahead of the curve. Thryve delivers next-generation...

  • Clinical Documentation Improvement Specialist

    4 weeks ago

    Hyderabad, Telangana, India Thryve Digital Health LLP Full time

    Thryve Digital Health LLP is an emerging global healthcare partner that delivers strategic innovation, expertise, and flexibility to its healthcare partners. Being a US healthcare conglomerate captive, we have direct access to deeper insights that help us accelerate our learning process and keeps us ahead of the curve. Thryve delivers next-generation...

  • Clinical Documentation Improvement Specialist

    4 days ago

    Hyderabad, Telangana, India Thryve Digital Health LLP Full time

    Thryve Digital Health LLP is an emerging global healthcare partner that delivers strategic innovation, expertise, and flexibility to its healthcare partners. Being a US healthcare conglomerate captive, we have direct access to deeper insights that help us accelerate our learning process and keeps us ahead of the curve. Thryve delivers next-generation...

  • Clinical Documentation Improvement Specialist

    4 weeks ago

    Hyderabad, Telangana, India Thryve Digital Health LLP Full time

    Thryve Digital Health LLP is an emerging global healthcare partner that delivers strategic innovation, expertise, and flexibility to its healthcare partners. Being a US healthcare conglomerate captive, we have direct access to deeper insights that help us accelerate our learning process and keeps us ahead of the curve. Thryve delivers next-generation...

  • Clinical Documentation Improvement Specialist

    2 days ago

    Hyderabad, Telangana, India Thryve Digital Health LLP Full time

    Thryve Digital Health LLP is an emerging global healthcare partner that delivers strategic innovation, expertise, and flexibility to its healthcare partners. Being a US healthcare conglomerate captive, we have direct access to deeper insights that help us accelerate our learning process and keeps us ahead of the curve. Thryve delivers next-generation...

  • Healthcare AR Specialist

    3 weeks ago

    Hyderabad, Telangana, India Doctus Data Services Private Limited Full time

    Job DescriptionJob Title: Healthcare AR SpecialistIndustry: US HealthcareEmployment Type: Full-Time | Night Shift (US Time Zone)Location: Office-Based | Immediate Joiners PreferredJoin a leading US healthcare revenue cycle team. Were hiring experienced Healthcare AR Specialists to manage accounts receivable, resolve denied claims, and drive reimbursement...