Clinical Documentation Improvement Specialist

Overview

• Clinical Documentation Review

• Review inpatient and outpatient medical records to ensure documentation is complete, accurate, and compliant.
• Identify gaps, inconsistencies, or missing clinical information.
• Conduct concurrent and retrospective chart reviews for documentation improvement opportunities.

• Physician Query & Engagement

• Issue compliant queries to physicians for clarification of diagnoses, procedures, or clinical conditions.
• Collaborate with physicians, nurses, and case management teams to ensure accurate representation of patient care.

• Coding & Revenue Cycle Support

• Work closely with coding teams to ensure proper DRG assignment and coding accuracy.
• Ensure documentation supports medical necessity, severity of illness (SOI), and risk of mortality (ROM).
• Assist in reducing denials and improving reimbursement accuracy
• Support reduction of medical necessity denials and revenue leakage
• Perform daily review of revenue optimization progress
• Coordinate closely with clinical, coding, and billing teams

• Education & Training

• Educate physicians and clinical staff on documentation best practices and regulatory requirements.
• Provide training on ICD-10, DRG documentation, and coding compliance.
• Share feedback on documentation deficiencies and improvement opportunities.

• Compliance & Audit

• Ensure adherence to regulatory standards, coding guidelines (ICD-10, CPT), and payer requirements.
• Participate in internal audits, documentation reviews, and quality assurance initiatives.
• Maintain compliance with organizational clinical documentation policies

• Data Analysis & Reporting

• Track CDI KPIs such as documentation completeness, query rates, and denial trends.
• Analyze trends to identify areas for improvement and provide recommendations.
• Prepare reports and dashboards for leadership review.

Key Skills & Competencies

• Strong knowledge of medical terminology, disease processes, and coding systems (ICD-10, CPT, DRG)
• Analytical skills to identify documentation gaps
• Excellent communication and physician engagement skills
• Knowledge of healthcare regulations and audit requirements
• Detail-oriented with strong problem-solving ability

Qualifications

• Bachelor’s degree in Nursing, Health Information Management, or related field
• Clinical background (e.g., RN, coder, case manager) preferred
• Minimum 2 years of experience in Clinical Documentation Improvement
• Minimum 4 years of medical coding experience in Abu Dhabi

• Certified Medical Coder

• Other certifications preferred: