CDI Specialist-Hyderabad location

Job description

**GREETINGS FROM R1RCM** **Clinical Documentation Improvement (CDI) Specialist** **We are seeking a motivated Nursing graduate with hospital experience to join our Clinical Documentation Improvement team. This role is ideal for a CDI fresher who has strong clinical knowledge, excellent communication skills, and an interest in medical documentation, quality outcomes, and healthcare reimbursement processes.** **The CDI Specialist will review inpatient medical records concurrently and retrospectively to identify opportunities for improving the quality and accuracy of clinical documentation. The role supports accurate reflection of severity of illness, risk of mortality, complexity of care, case mix index (CMI), length of stay (LOS), and resource utilization. The specialist will work closely with physicians, coders, auditors, and quality teams to ensure complete and compliant documentation.** **Key Responsibilities** - **Review inpatient medical records concurrently and retrospectively to identify documentation improvement opportunities.** - **Identify ambiguous, missing, incomplete, or conflicting documentation in the medical record.** - **Initiate physician queries, as appropriate, to obtain clear and accurate clinical documentation.** - **Support accurate reflection of severity of illness, risk of mortality, case mix index, length of stay, and resource utilization.** - **Collaborate with coding, auditing, quality, and clinical teams to resolve documentation-related issues.** - **Participate in focused documentation reviews such as mortality reviews, PSI reviews, and other special projects as assigned.** - **Assist in maintaining documentation quality in line with organizational policies, coding guidelines, and regulatory requirements.** - **Learn and apply clinical documentation improvement concepts, coding basics, DRG understanding, and compliance standards during training and on the job.** - **Participate in formal and informal education sessions related to CDI, clinical documentation, and quality improvement.** - **Stay updated with changing clinical documentation standards, reimbursement rules, and regulatory requirements.** - **Perform other duties as assigned.** **Eligibility Criteria** - **Education:** **B.Sc. Nursing required** - **Experience:** **Minimum** **5 years of hospital/clinical experience** **required** - **Experience in areas such as** **Medical-Surgical, ICU, Telemetry, or Emergency Department** **will be preferred** - **NCLEX-certified RNs** **preferred, if available** **Required Skills** - **Strong clinical knowledge and understanding of patient care documentation** - **Good understanding of medical terminology, disease processes, and clinical indicators** - **Strong analytical and critical thinking skills** - **Good written and verbal communication skills** - **Ability to work independently and in a fast-paced environment** - **Effective interpersonal skills and ability to collaborate with physicians and internal teams** - **Willingness to learn CDI practices, coding basics, reimbursement concepts, and documentation requirements** - **Basic computer skills including** **Microsoft Word, Excel, PowerPoint, Outlook, and email** - **Familiarity with EMR/EHR systems preferred** - **Ability to provide and receive constructive feedback professionally** - **Self-motivated, flexible, and able to work with minimal supervision** **Training and Shift Requirement** - **Candidates must be available to work in the** **US shift during the initial 12 weeks of training** - **After successful completion of the 12-week training period, the shift will move to the** **morning shift** **Work Environment** - **Work from office. It is dependent on business requirement.** - **Quiet, well-lit, and climate-controlled work environment** - **Extended computer usage required** **Physical Demands** - **Sitting** - **Standing** - **Extended computer usage** **if interested share resume to Hpalaniappan@r1rcm.com/9677152997** **contact HR** **Harrishma** **9677152997** **hpalaniappan@r1rcm.com**