Clinical Documentation Improvement
6 days ago
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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