Clinical Documentation Improvement Lead

2 days ago

Hyderabad, Telangana, India beBeeClinical Full time ₹ 15,00,000 - ₹ 18,00,000
Job Description

As a senior clinical documentation improvement specialist, you will play a pivotal role in enhancing the accuracy and completeness of medical record documentation.

Key Responsibilities:
  1. 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.
  2. 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.
    • Develop and deliver educational materials, presentations, and workshops on CDI topics.
  3. Coding and Reimbursement:
    • Ensure that documentation supports accurate coding and billing practices.
    • Collaborate with coding staff to resolve coding discrepancies and documentation issues.
    • Stay current on changes in coding guidelines (ICD-10, CPT, HCPCS) and reimbursement policies.
  4. 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.
  5. 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.
  6. 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.
  7. System Proficiency:
    • Utilize electronic health record (EHR) systems and CDI software to manage medical record reviews and documentation queries.

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