Job
Description
Position Summary: The ED CDI Specialist is responsible for enhancing the quality and accuracy of clinical documentation in the Emergency Department to ensure compliance with regulatory standards, optimize reimbursement, and improve patient care outcomes. This role involves collaborating with coders, auditors, clients, physicians and other healthcare providers to ensure that documentation reflects the true clinical picture of patients' conditions and treatments. Key Responsibilities: Documentation Review: Perform regular audits of clinical documentation in the ED to identify areas for improvement, ensuring accuracy and completeness of report. Education and Training: Provide ongoing education and training to ED staff on best practices for clinical documentation, including coding guidelines and regulatory requirements. Collaboration: Work closely with coders/QA staff/Leadership, ED physicians and clinical staff to clarify documentation issues and promote accurate coding and reporting. Data Analysis: Analyze documentation trends and outcomes to identify opportunities for improvement in clinical practices and documentation accuracy. Compliance Monitoring: Ensure adherence to CMS guidelines and other regulatory requirements related to clinical documentation. Feedback and Reporting: Develop and present reports on documentation improvement initiatives and outcomes to immediate supervisor, stakeholders and Senior leadership. Quality Improvement: Participate in quality improvement initiatives aimed at enhancing patient care and safety in the ED. Professional Development: 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. Work Environment: Primarily in the Emergency Department with interactions across various departments. Ability to work in a fast-paced clinical environment in a US shift time zone. Medical coding -Interventional radiology Chennai & Hyderabad Roles and Responsibilities: - Hands on experience in diagnostic angiography, percutaneous vascular interventions non-vascular interventions, diagnostic/therapeutic cardiac catheterization, coronary arterial interventions etc. Knowledge of anatomy and terminology pertaining to vascular families and specificities. Review clinical reports related to interventional radiology procedures. Ensure coding is compliant with relevant coding guidelines, including CPT, ICD-10, and other applicable regulations. Hands on experience in 3M and or Encoder and EPIC application. Review medical documentation to extract relevant information for coding purposes, specifically related to Interventional radiology services. Collaborate with healthcare providers to clarify documentation when necessary. Productivity and Timeliness: Meet productivity targets while maintaining high-quality coding standards. Ensure timely completion of coding assignments for interventional radiology services. Collaboration: Work collaboratively with other coding professionals, healthcare providers, and administrative staff to resolve coding-related issues Provide coding-related training and support to colleagues as needed. Compliance: Adhere to coding compliance standards and regulations, including HIPAA Stay informed about changes in coding guidelines and regulations affecting Interventional radiology coding. Desired Candidate Profile: - Should be a Life Science Graduate. Minimum of 1+ years of experience in Interventional radiology coding or Surgery is required Basic knowledge of medical terminology and anatomy. Comfortable to work from office. Effective verbal and written communication skills (Should have capability to reply properly to client and stakeholders. Successful completion of CPC or CCS certification must be active during joining and verified. Able to work independently and willing to adapt and change as per business/ process requirements.
