Clinical Documentation Integrity Specialist (CDIS)- Non Hospital

Jobdescription

Greeting from Optum!!

Onlyapplicantswhoareseekingashiftfromhospital/clinicalenvironment setuptoacorporateworkenvironmentcanapplyforthisrole.

Job Title: Clinical Documentati on Integrity Specialist(CDIS)

Role Overview: The Clinical Documentati on Integrity Specialistisresponsiblefortheday-to-dayimplementationofprocessesrelatedtothereviewofinpatientmedicalrecords. Thisroleiscenteredonassessingaccuracy, specificity, andcompletenessofproviderclinicaldocumentation. Theprimaryobjectiveistoensurethatdocumentationexplicitlyidentifiesallclinicalfindingsandconditionspresentatthetimeofservicetoaccuratelyreflecttheseverityofthepatient'sconditionandtheacuityofcareprovided.
*Pleasenotethataccordingtothesources, thispositiondoesnothavepatientcareduties, directpatientinteractions, oranyrolerelatedtopatientcare.

Key Responsibilities
Clinical Documentati on Review
• Performexpert-levelconcurrentreviewsofinpatientmedicalrecordswith in 2448 hours

ofadmission.
• Identifydocumentationgaps, inconsistencies, orinsufficientspecificityimpactingdiagnosiscapture, Principaldiagnosis, SOI/ROM, DRGassignment, andqualitymetrics.

Clinical Clarification&Query Management
• Initiateandmanagecompliantqueriesexclusivelythroughelectronicmeans, toobtainnecessaryclinicalclarification.

• Ensurequeriesareclinicallysupported, non-leading, andaligned with AHIMAand

organizationalquerystandards.
• Conductdailyfollow-uponoutstandingqueriestosupporttimelydocumentationresolution.

Documentation&System Utilization
• Accuratelydocumentallreviewfindings, monitorandresolvequeries, responses, and

outcomesusingapproved CDItoolsandplatforms(e.g., Mid as Clinical Documentati on Improvement Focus Studyorequivalentsystems).
• Maintainclearnotesforaudittrailstosupportinternalreviewandexternalaudits.

Education&Continuous Improvement
• Participateinstructuredphysicianeducationinitiativestoenhanceawarenessof

documentationrequirementsandbestpractices.
• Staycurrentwithevolvingdocumentation, coding, andregulatoryguidelinesaffecting

inpatientreimbursementandqualityoutcomes.
Collaboration&Interdisciplinary Engagement
• Workcollaboratively with Medical Coding Professionalstoreconciledocumentationand

final DRGassignment.
• Partnerwith the Onshore Teamwhointeracts with Physici an Advisors, Carecoordination and Quality Managementteamstoidentifysystemicdocumentationimprovementopportunities.

• Supportorganizationalinitiativesrelatedtodocumentationaccuracy, compliance, andperformanceimprovement.

Qualifications and Requirements
• Education: Mustpossessavalid MBBSdegree(Indian/FMGcredentials).

• Experience: Experienceinpatienthandlingandcare, criticalcareorcasemanagementispreferredasitprovidesafoundationalunderstandingofcomplexpatientneeds, resourceallocation, andtheinterdisciplinarycoordinationrequiredinhigh-acuityhealthcaresettings.

• Communicati on Skills: Mustpossessexcellentverbalandwrittenskillstoeffectivelyarticulatedocumentgapsandprovidetherationaleforclinicalqueries.

Note: Thereisnoface-to-faceinteractionwithphysiciansduetotheoffshorenatureoftherole.
• Technical Skills: Basicunderstanding of Microsoft Word, Excel, andbasicunderstanding of EMR/EHR

• Certifications: Whilenotmandatory, arelevantcertificationsuchas the Certified Clinical Documentati on Specialist(CCDS)ispreferred.

• Standards Knowledge: Basicfamiliaritywithhealthcarecompliance, clinicaldocumentation, medicaltermsandconcepts, HIPAA, andthegeneralideaofmedicalcoding(ICD-10). Anyenhancedknowledge of ICD-10 willbepreferential.

Location: Chennai
WFO

Contact Details:
[contact shared on WhatsApp]