Clinical Documentation Improvement

4 days ago

Pasay, National Capital Region, Philippines Access Healthcare Services Manila, Inc. Full time ₱900,000 - ₱1,200,000 per year

Access Healthcare is looking for highly skilled and detail-oriented Clinical Documentation Improvement (CDI) Specialists to join our dynamic pioneer medical coding team. The ideal candidate will play a pivotal role in enhancing the quality and accuracy of clinical documentation to support optimal patient care and compliance with regulatory standards.

Key Responsibilities

  • Collaborate with physicians, nurses, and other healthcare professionals to ensure complete and accurate documentation in patient medical records.
  • Review medical records to identify documentation gaps, inconsistencies, or errors and recommend appropriate changes.
  • Conduct in-depth chart reviews for compliance with coding and clinical guidelines, focusing on in-patient coding.
  • Provide education and feedback to healthcare staff on proper documentation practices, coding requirements, and regulatory changes.
  • Analyze data trends and provide actionable insights to improve documentation processes.
  • Participate in interdisciplinary team meetings to discuss documentation improvement opportunities.
  • Ensure compliance with HIPAA and other relevant regulations in all documentation activities.
  • Collaborate with quality assurance teams to monitor and report on CDI metrics and performance.

Qualifications

  • Education: Must a Registered Nurse with Active PRC license
  • Certification: Active In-Patient Coding Certification (e.g., CCS, RHIA, or equivalent).

Experience:

  • At least 1 year of in-patient coding / CDI experience.
  • At least 1 year bedside experience
  • Experience in a BPO setting is an advantage.

Skills:

  • Strong knowledge of ICD-10-CM/PCS coding guidelines and clinical terminologies.
  • Excellent communication and interpersonal skills to collaborate with various stakeholders.
  • Proficient in electronic medical record (EMR) systems and CDI tools.
  • Analytical mindset with attention to detail.
  • Ability to educate and influence clinical staff effectively.

Key Competencies

  • Strong understanding of healthcare documentation standards and coding regulations.
  • Ability to work in a fast-paced and dynamic environment.
  • Effective problem-solving and critical thinking skills.
  • Commitment to maintaining patient confidentiality and data security.

Why Join Us?

  • Competitive salary and benefits package.
  • Opportunities for professional growth and career advancement.
  • Collaborative work culture and supportive team environment.
  • Exposure to international healthcare documentation standards.

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