Outpatient Clinical Documentation Improvement CDI Specialist Location Hyderabad India Employment Type Full-Time Position Summary The Outpatient Clinical Documentation Improvement CDI Specialist is responsible for ensuring the accuracy completeness and compliance of clinical documentation in outpatient medical records This role collaborates with healthcare providers coding staff and compliance teams to improve documentation quality support accurate coding and ensure appropriate reimbursement while maintaining regulatory compliance The CDI Specialist plays a critical role in enhancing patient care quality data integrity and revenue cycle efficiency in an outpatient setting Key Responsibilities Documentation Review Conduct concurrent and retrospective reviews of outpatient medical records to ensure documentation accurately reflects the patient s clinical condition treatment and services provided Provider Education Collaborate with physicians nurse practitioners and other healthcare providers to educate them on documentation best practices including specificity and completeness to support accurate coding and billing Query Process Issue compliant non-leading queries to providers to clarify ambiguous incomplete or conflicting documentation ensuring alignment with ICD-10-CM CPT and Outpatient coding guidelines Coding Support Work closely with coding and billing teams to ensure documentation supports appropriate code assignment risk adjustment and reimbursement Compliance Ensure documentation meets regulatory requirements including CMS HIPAA and other federal and state guidelines to minimize audit risks Data Analysis Monitor and analyze documentation trends identifying opportunities for improvement in clinical documentation processes and provider education Quality Improvement Participate in quality improvement initiatives to enhance patient outcomes documentation accuracy and organizational performance metrics Qualifications Education Science Graduate or Postgraduate Experience Minimum of 5 years of experience in clinical documentation improvement medical coding or outpatient healthcare settings Robust knowledge of outpatient coding methodologies ICD-10-CM CPT HCPCS and risk adjustment models Certifications one or more preferred Certified Clinical Documentation Specialist CCDS or Certified Documentation Improvement Practitioner CDIP Certified Professional Coder CPC or Certified Coding Specialist CCS Skills Excellent understanding of clinical terminology disease processes and treatment protocols Strong analytical skills to interpret clinical documentation and identify gaps Exceptional communication and interpersonal skills to engage with providers and interdisciplinary teams Proficiency in EHR systems e g Epic Cerner and CDI software tools Detail-oriented with a commitment to accuracy and compliance Preferred Qualifications Experience in outpatient or ambulatory care settings such as clinics physician practices or urgent care facilities Knowledge of value-based care models and their impact on documentation and reimbursement Familiarity with payer-specific documentation requirements e g Medicare Advantage Medicaid Requires the ability to work independently and collaboratively in a fast-paced environment Why Join Us This role offers a unique opportunity to make a meaningful impact on healthcare quality and reimbursement accuracy Join a collaborative and supportive team committed to excellence in clinical documentation compliance and patient outcomes at Doctus Take the Next Step in Your CDI Career Apply now and play a key role in shaping the future of clinical documentation integrity Job Type Full-time Benefits Health insurance Provident Fund Work Location In person