Role & responsibilities

By embodying our core purpose of customer obsession, new ideas, and driving innovation, and delivering excellence, you will help ensure that every touchpoint is meaningful and contributes to our mission of redefining the possible in healthcare.

Advanced CDI specialist position that is responsible forreviewing and improving the accuracy, completeness, and quality of clinical documentation in patient records.

Preferred candidate profile and Expertise:

- Clinical Knowledge & Expertise: Strong understanding of anatomy, pathophysiology, and pharmacology.
- Coding & Regulatory Knowledge:Proficiency in ICD-10-CM/PCS coding systems, APR-DRGs, MS-DRGs, and understanding CMS guidelines for accurate reimbursement.
- Medical Record Review/Analysis: Ability to review clinical documentation for inconsistencies, inaccuracies, and missing information, identifying opportunities to improve specificity.
- Physician Communication & Education: Strong verbal and written communication skills to engage with providers, explaining the need for more specific documentation.
- Technical Proficiency: Skill with electronic health records (EHR) and computer systems (e.g., Microsoft Office suite) CDI software, to manage patient data and track queries.
- Critical Thinking & Attention to Detail: A high degree of accuracy is needed to ensure the patients full severity of illness (SOI) and risk of mortality (ROM) are captured.

Graduate in life sciences (B.Sc./M.Sc. Nursing, B. Pharm, M. Pharm, or Life Sciences).

Certifications: Mandatory or highly preferred include:

- Certified Documentation Integrity Practitioner (CDIP) (AHIMA).
- Certified Documentation Expert Inpatient (CDEI) (AAPC).
- Certified Clinical Documentation Specialist (CCDS/CCDS-O).

One plus year of experience in clinical documentation or health information management.

Strong communication, organizational, and problem-solving skills. Ability to work in a fast-paced setting and manage multiple priorities.

Essential Job Functions

CDI Process & Workflow:





- Conduct chart reviews, provide education on documentation best practices, and identify opportunities for process improvement.
- Maintain confidentiality, demonstratestrong communication skills, and contribute to high-quality patient care documentation.
- Conduct retrospective reviews for Mortality, Hospital Acquired Conditions (HAC) and Patient Safety Indicators (PSI) accounts.
- Apply clinical expertise to educate stakeholders on documentation standards and collaborates to identify improvement opportunities based on quality and value-based purchasing trends.

Job Competencies

Valuing Differences - Works effectively with individuals of diverse cultures, interpersonal styles, abilities, motivations, or backgrounds; seeks out and uses unique abilities, insights, and ideas. Considers the collective.

Collaboration - Works cooperatively within teams and partners with others, both internally and externally as needed, to achieve success; focuses on the results of the team, not the achievements of one person. Its All for One and One for All.

Accountability - Accepts personal responsibility and/or consequences of failure and successes, delivering on commitments and refocusing effort when needed. Someone who is willing to step up and own it.

Time Management - Effectively manages personal time and resources to ensure that work is completed efficiently.

Developing Trust - Gains others’ confidence by acting with integrity and following through on

Commitments. Treats others and their ideas with respect and supporting them in the face of challenges.

Takes Initiative - Takes prompt action to accomplish goals and achieve results beyond what is required, is proactive and pursues relentlessly.

Customer Obsession - Consistently provide exceptional experience for our clients, patients, and colleagues by understanding their needs and exceeding their expectations.

Embracing New Ideas - Continuously innovate by embracing emerging technology and fostering a culture of creativity and experimentation.

For more Information send your CV [email protected] or call (phone hidden)

📌 Opening For Clinical Documentation - CDI Specialist (Hyderabad)
🏢 Orcapod Consulting Services
📍 Hyderabad