ED CDI Specialist

Role Overview: As an Emergency Department Clinical Documentation Improvement (ED CDI) Specialist in the Clinical Documentation Improvement department at Chennai/Hyderabad, you will play a crucial role in enhancing the quality and accuracy of clinical documentation in the Emergency Department. Your responsibilities will involve collaborating with various stakeholders to ensure compliance with regulatory standards, optimize reimbursement, and improve patient care outcomes. Key Responsibilities: - Perform regular audits of clinical documentation in the ED to identify areas for improvement, ensuring accuracy and completeness of reports. - Provide ongoing education and training to ED staff on best practices for clinical documentation, including coding guidelines and regulatory requirements. - Work closely with Coders/QA staff/Leadership/Clients, ED physicians, and clinical staff to clarify documentation issues and promote accurate coding and reporting. - Analyze documentation trends and outcomes to identify opportunities for improvement in clinical practices and documentation accuracy. - Ensure adherence to CMS guidelines and other regulatory requirements related to clinical documentation. - Develop and present reports on documentation improvement initiatives and outcomes to immediate supervisor, stakeholders, and Senior leadership. - Participate in quality improvement initiatives aimed at enhancing patient care and safety in the ED. - Stay current with developments in clinical documentation and coding standards through continuing education and professional organizations. Qualifications: - Education: Masters/bachelors degree in any life science stream - Medicine, Physiotherapy, Occupational Therapy, Physician Assistant, Nursing, Pharmacy, Biomedical, Biochemistry, Microbiology, health information management, or related field. - Experience: Minimum of 4-5 years of clinical experience in an emergency department setting, with at least 2 years in clinical documentation improvement or coding. - Certifications: CPC, Certified Clinical Documentation Specialist (CCDS), Certified Documentation Integrity Practitioner (CDIP) or equivalent certification preferred. - Skills: Strong knowledge of medical terminology, anatomy, physiology, coding guidelines (ICD-10, CPT, Modifiers, Category II codes), and clinical documentation standards with excellent communication, analytical, and problem-solving skills. - Technology Proficiency: Proficiency in electronic health record (EHR) systems and clinical documentation improvement software. (Note: Work Environment details are omitted as they are not directly related to the job responsibilities),