Clinical Documentation Integrity Specialist (CDIS)- Non Hospital

Job description

Greeting from Optum!!

Only applicants who are interested and planning to shift there carrier from hospital/clinical environment setup to a corporate work environment can apply for this role.

Job Title: Clinical Documentation Integrity Specialist (CDIS)

Role Overview: The Clinical Documentation Integrity Specialist is responsible for the day-to-day implementation of processes related to the review of inpatient medical records. This role is centered on assessing accuracy, specificity, and completeness of provider clinical documentation. The primary objective is to ensure that documentation explicitly identifies all clinical findings and conditions present at the time of service to accurately reflect the severity of the patient's condition and the acuity of care provided.

*Please note that according to the sources, this position does not have patient care duties, direct patient interactions, or any role related to patient care.

Key Responsibilities

Clinical Documentation Review

• Perform expert-level concurrent reviews of inpatient medical records within 2448 hours

of admission.

• Identify documentation gaps, inconsistencies, or insufficient specificity impacting diagnosis capture, Principal diagnosis, SOI/ROM, DRG assignment, and quality metrics.

Clinical Clarification & Query Management

• Initiate and manage compliant queries exclusively through electronic means, to obtain necessary clinical clarification.
• Ensure queries are clinically supported, non-leading, and aligned with AHIMA and

organizational query standards.

• Conduct daily follow-up on outstanding queries to support timely documentation resolution.

Documentation & System Utilization

• Accurately document all review findings, monitor and resolve queries, responses, and

outcomes using approved CDI tools and platforms (e.g., Midas Clinical Documentation Improvement Focus Study or equivalent systems).

• Maintain clear notes for audit trails to support internal review and external audits.

Education & Continuous Improvement

• Participate in structured physician education initiatives to enhance awareness of

documentation requirements and best practices.

• Stay current with evolving documentation, coding, and regulatory guidelines affecting

inpatient reimbursement and quality outcomes.

Collaboration & Interdisciplinary Engagement

• Work collaboratively with Medical Coding Professionals to reconcile documentation and

final DRG assignment.

• Partner with the Onshore Team who interacts with Physician Advisors, Care coordination and Quality Management teams to identify systemic documentation improvement opportunities.
• Support organizational initiatives related to documentation accuracy, compliance, and performance improvement.

Qualifications and Requirements

• Education: Must possess a valid MBBS degree (Indian/FMG credentials).
• Experience: Experience in patient handling and care, critical care or case management is preferred as it provides a foundational understanding of complex patient needs, resource allocation, and the interdisciplinary coordination required in high-acuity healthcare settings.
• Communication Skills: Must possess excellent verbal and written skills to effectively articulate document gaps and provide the rationale for clinical queries.

Note: There is no face-to-face interaction with physicians due to the offshore nature of the role.

• Technical Skills: Basic understanding of Microsoft Word, Excel, and basic understanding of EMR/EHR
• Certifications: While not mandatory, a relevant certification such as the Certified Clinical Documentation Specialist (CCDS) is preferred.
• Standards Knowledge: Basic familiarity with healthcare compliance, clinical documentation, medical terms and concepts, HIPAA, and the general idea of medical coding (ICD-10). Any enhanced knowledge of ICD-10 will be preferential.

Location : Chennai

WFO

Contact Details:

[email removed]