We are looking for a Clinical Documentation Integrity (CDI) E/M Outpatient (EM OP) skilled with strong knowledge of outpatient E/M coding, clinical documentation, and medical necessity.

The role involves reviewing outpatient medical records, identifying documentation gaps, and ensuring that clinical documentation accurately supports the services, diagnoses, and E/M level reported.

Interview Process:

- Personal Information
- Screening Question
- Video Interview

Key Responsibilities

- Review outpatient medical records for accuracy, completeness, specificity, and clinical consistency.
- Validate documentation to support appropriate E/M code selection and level of service.
- Evaluate E/M services based on Medical Decision Making (MDM) and/or time, as applicable.
- Review documentation related to:
- Problems addressed and their complexity
- Data reviewed and analyzed
- Risk of patient management
- Total time documentation, when applicable

- Identify documentation gaps, inconsistencies, and conflicting information.
- Prepare compliant provider queries and clarification requests when additional documentation is required.
- Ensure documentation supports reported diagnoses, procedures, medical necessity, and services provided.
- Review various outpatient E/M encounters, including office visits, outpatient/clinic services, emergency department services, preventive services, and other applicable professional services.
- Collaborate with physicians, coders, auditors,



and operational teams to improve documentation and coding accuracy.
- Provide education and feedback on documentation improvement opportunities.
- Identify recurring documentation and coding trends and recommend appropriate corrective actions.
- Support internal and external audits and assist with documentation-related findings.
- Maintain required quality, productivity, and turnaround-time standards.
- Maintain patient confidentiality and comply with all applicable privacy, security, and compliance requirements.

Required Skills & Knowledge

- Strong knowledge of Outpatient E/M coding and documentation guidelines.
- Good understanding of CPT, ICD-10-CM, HCPCS, and medical terminology.
- Strong understanding of E/M Medical Decision Making (MDM).
- Ability to interpret physician documentation and correlate diagnoses with clinical information.
- Knowledge of medical necessity and documentation compliance.
- Strong analytical and critical-thinking skills.
- Excellent written and verbal communication skills.
- Ability to communicate documentation opportunities professionally with providers and internal stakeholders.
- Strong attention to detail and commitment to documentation accuracy.

HR Details - Sandhiya - (phone hidden) OR [email protected]

Important Notice: Sutherland never requests payment or favors in exchange for job opportunities. Please report any suspicious activity to [email protected].

📌 CDI - Outpatient EM Specialist (Hyderabad)
🏢 Sutherland
📍 Hyderabad