Clinical Documentation Improvement Specialist
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Key skills for this role
About the Role
Healthpoint is hiring a Clinical Documentation Improvement Specialist to ensure accuracy and compliance of clinical documentation. The role involves reviewing medical records, issuing physician queries, supporting coding and revenue cycle, and providing education.
Key Skills for This Role
Responsibilities
- 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
- 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
- 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
- Educate physicians and clinical staff on documentation best practices and regulatory requirements
- Track CDI KPIs such as documentation completeness, query rates, and denial trends
Requirements
- Bachelor’s degree in Nursing, Health Information Management, or related field
- Minimum 2 years of experience in Clinical Documentation Improvement
- Minimum 4 years of medical coding experience in Abu Dhabi
- Certified Medical Coder
- Clinical background (e.g., RN, coder, case manager) preferred
- CCDS (Certified Clinical Documentation Specialist) preferred
- CDIP (Clinical Documentation Improvement Practitioner) preferred
Full Job Posting
Overview
- M42 delivers comprehensive healthcare services across the full continuum of care; from primary care to advanced specialty treatments.
- Healthpoint is a multi specialty hospital offering a wide range of primary and specialty care services, based in Abu Dhabi.
- This role is responsible for ensuring the accuracy, completeness, and compliance of clinical documentation in patient medical records.
Responsibilities
- 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.
- 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.
- 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.
- Educate physicians and clinical staff on documentation best practices and regulatory requirements.
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: CCDS (Certified Clinical Documentation Specialist), CDIP (Clinical Documentation Improvement Practitioner).
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