CDI - Outpatient EM Specialist

We are looking for a Clinical Documentation Integrity (CDI) E/M Outpatient (EM OP) professional with strong knowledge of outpatient E/M coding, clinical documentation, and medical necessity.

The role involves reviewing outpatient medical records, identifying documentation gaps, and ensuring that clinical documentation accurately supports the services, diagnoses, and E/M level reported.

Interview Process:

• Personal Information
• Screening Question
• Video Interview

Key Responsibilities

• Review outpatient medical records for accuracy, completeness, specificity, and clinical consistency.
• Validate documentation to support appropriate E/M code selection and level of service.
• Evaluate E/M services based on Medical Decision Making (MDM) and/or time, as applicable.
• Review documentation related to:
• Problems addressed and their complexity
• Data reviewed and analyzed
• Risk of patient management
• Total time documentation, when applicable
• Identify documentation gaps, inconsistencies, and conflicting information.
• Prepare compliant provider queries and clarification requests when additional documentation is required.
• Ensure documentation supports reported diagnoses, procedures, medical necessity, and services provided.
• Review various outpatient E/M encounters, including office visits, outpatient/clinic services, emergency department services, preventive services, and other applicable professional services.
• Collaborate with physicians, coders, auditors, and operational teams to improve documentation and coding accuracy.
• Provide education and feedback on documentation improvement opportunities.
• Identify recurring documentation and coding trends and recommend appropriate corrective actions.
• Support internal and external audits and assist with documentation-related findings.
• Maintain required quality, productivity, and turnaround-time standards.
• Maintain patient confidentiality and comply with all applicable privacy, security, and compliance requirements.

Required Skills & Knowledge

• Strong knowledge of Outpatient E/M coding and documentation guidelines.
• Good understanding of CPT, ICD-10-CM, HCPCS, and medical terminology.
• Strong understanding of E/M Medical Decision Making (MDM).
• Ability to interpret physician documentation and correlate diagnoses with clinical information.
• Knowledge of medical necessity and documentation compliance.
• Strong analytical and critical-thinking skills.
• Excellent written and verbal communication skills.
• Ability to communicate documentation opportunities professionally with providers and internal stakeholders.
• Strong attention to detail and commitment to documentation accuracy.

HR Details - Sandhiya - [phone removed] OR [email removed]

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