Job Title: Emergency Department Clinical Documentation Improvement (ED CDI) Specialist

Location: Chennai/Hyderabad

Level: L2

Department: Clinical Documentation Improvement

Reports To: Coding Manager

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/Clients, 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/bachelor’s 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.

 Work from office is mandatory

Renumeration:

 Best as per the market standards