Clinical Documentation Integrity (CDI) Specialist

Concurrent Urgent Care Documentation Review & Care-Continuity Support

Position Type: Outsourced / Remote

Department: Clinical Documentation Integrity / Health Information Management / Ambulatory Operations

Shift: 5:30 PM to 1:30 AM IST

Position Overview

We are seeking an experienced outpatient CDI professional to support a multi-site urgent care operation through concurrent documentation review. Rather than reviewing charts after the patient has gone home, you will review documentation while the encounter is still open, so that the record is complete, specific, internally consistent, and an accurate reflection of what the treating provider assessed, decided, and planned.

You will also help strengthen continuity of care. When a provider documents a follow-up plan or orders a referral, you will make sure the documentation is complete and that the decision reaches the care-coordination team before the patient leaves, so patients have a clear next step instead of relying on returning to urgent care when symptoms recur.

This is an administrative documentation role. Clinical decisions, including diagnosis, testing, treatment, and referral decisions, rest with the licensed treating provider. Your work makes those decisions visible, specific, and complete in the record.

How the Roles Works:

- Registration: the patient's reason for visit is captured.
- Concurrent review begins: you review the encounter as documentation develops and identify missing, ambiguous, or conflicting elements.
- Provider query: when documentation warrants clarification, you send a neutral, non-leading query supported by clinical indicators already in the record.
- Provider documents and decides: the provider responds in whatever way their clinical judgment dictates.
- Provider-directed follow-up is coordinated: where the provider has documented a follow-up plan or placed a referral order, you confirm the documentation is complete and hand it to care coordination before discharge.

Core Responsibilities 1. Concurrent Documentation Review

- Begin review once registration and the chief complaint are documented and continue through the provider encounter.
- Identify missing, incomplete, ambiguous, or conflicting documentation, including onset, duration, severity, site and laterality, history, examination findings, assessment, and plan.
- Confirm that assessments and plans are consistent across the provider note, orders, and discharge instructions.
- Monitor open encounters so that queries can be resolved before the patient leaves wherever feasible, without disrupting patient care.

2. Compliant Provider Queries

- Write clear, neutral, non-leading queries supported by patient-specific clinical indicators documented in the record.
- Use open-ended or multiple-choice formats. Multiple-choice options must be clinically supported by the record and must always include "other" and "unable to determine."
- Never reference reimbursement, quality scores, or other financial impact in a query, and accept any provider response, including no change.




- Follow the organization's query policy and current industry guidance on compliant query practice.

3. ICD-10-CM Knowledge and Documentation Specificity

- Apply advanced working knowledge of ICD-10-CM conventions and outpatient reporting guidelines, including how uncertain diagnostic statements are handled in the outpatient setting.
- Recognize when documentation is symptom-level, nonspecific, or missing elements such as site, laterality, acuity, or type, and request clarification to the extent the provider can clinically determine.
- Partner with coding staff; diagnosis code assignment remains a coding function based on provider documentation.
- Support documentation that clearly reflects the provider's own clinical rationale for the services rendered.

4. Clinical Knowledge Applied to Documentation Review

- Use working knowledge of clinical terminology, common symptom presentations, disease processes, and specialty service lines to recognize when documented information may warrant clarification.
- That knowledge informs what questions can appropriately be asked about the documentation. It does not substitute for the provider's judgment about the patient.

5. Care-Continuity Support and Care Coordination

- When a provider documents a follow-up plan or places a referral order, confirm the documentation is complete, including the reason for referral, pertinent history, available results, and any urgency specified by the provider.
- Communicate provider-directed follow-up to the care-coordination team before discharge, and help ensure patients can choose where they receive follow-up care.
- Track handoff completion with coordination teams and report documentation-related barriers.

6. Escalation

- If anything in the record suggests a patient-safety concern, notify the treating provider or in office clinical leadership promptly through the organization's escalation process rather than waiting for a routine query response.
- Escalate query disagreements and recurring documentation concerns according to policy.

7. Quality Reporting and Education

- Report aggregate trends in documentation gaps, query volume, and response times by site and template.
- Share documentation education opportunities with providers, coding, and operations leaders.

What Success Looks Like

Your performance will be measured by:

- completeness and specificity of encounter documentation;
- the quality of your queries: neutral, supported by clinical indicators, and consistent with policy;
- query turnaround time;
- completeness and timeliness of care-coordination handoffs for provider-directed follow-up; and
- collaboration with providers, coding, and care-coordination teams.

Performance is not measured by numbers of diagnoses, referrals, prescriptions, procedures, or any financial result.

Working Familiarity with Service Lines





Care coordination goes more smoothly when you know what receiving clinics typically request with a provider-ordered referral. The list below is illustrative; always follow the receiving clinic's current requirements and the provider's orders.

• Neurology: symptom history, frequency and duration, treatments tried, neurological examination documentation, relevant imaging.

• Spine / PM&R; / Physical Therapy: site and duration of symptoms, functional limitations, prior treatment, imaging, examination findings, and therapy orders exactly as written by the provider.

• Gastroenterology: symptom history and duration, prior treatment, relevant laboratory and imaging results.

• Cardiology: symptom history, ECG tracing and interpretation, medication list, relevant laboratory results.

• Orthopedics / Rheumatology: joint(s) involved and laterality, duration, imaging and laboratory results, prior treatment.

• ENT: symptom history and duration, examination findings, prior treatment, any audiology or imaging results.

• Endocrinology / Primary Care: relevant laboratory results, medication list, prior treatment.

• Dermatology: lesion description and location, duration, prior treatment, photographs where permitted by policy.

• Urology: symptom history, urinalysis and culture results, prior treatment.

• Behavioral Health: screening results if administered, provider documentation, and the referral order.

Acute or emergent concerns are handled through the clinic's clinical escalation process, not routine referral coordination.

Required Knowledge & Qualifications

Strongly preferred:

- CCDS-O, CCDS, CDIP, or equivalent CDI experience
- Advanced knowledge of ICD-10-CM coding guidelines and diagnosis specificity, including outpatient reporting conventions
- Outpatient CDI experience, ideally in urgent care or other high-volume ambulatory settings
- Working knowledge of common symptoms, disease processes, clinical terminology, and specialty service lines
- Familiarity with medical-necessity documentation requirements and referral documentation requirements
- Ability to review EHR documentation concurrently with an active encounter
- Experience writing compliant, non-leading provider queries and following escalation procedures

Clinical licensure: A clinical license is not required for this position. The role is administrative and does not involve clinical practice. Clinical knowledge gained through nursing, coding, HIM, or CDI experience is valued.

Primary Objective To ensure that every urgent care encounter has complete, accurate, specific, and internally consistent documentation of the provider's findings, assessment, and plan, and that provider-directed follow-up is communicated to care-coordination teams before the patient leaves.

The broader goal is to support an urgent care model that functions as a well-documented, well-coordinated entry point to continuing care, improving continuity and the patient experience.

All work follows HIPAA. OptiClaim is an equal opportunity employer.

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📌 Clinical Documentation Integrity (CDI) Specialist (India)
🏢 OptiClaim
📍 India