01Overview
A Clinical Documentation Specialist (CDS), or Clinical Documentation Improvement (CDI) specialist, reviews inpatient or outpatient medical records for completeness, accuracy, and compliance.
They act as a bridge between healthcare providers, coders, and administration to ensure patient records accurately reflect clinical severity and support correct medical coding and reimbursement.
Core Responsibilities
Record Review: Perform concurrent or retrospective reviews of patient medical charts and clinical notes.
Provider Collaboration: Communicate and clarify gaps or discrepancies with physicians and nurses to ensure documentation matches actual patient care.
Compliance & Coding Support: Align documentation with regulatory standards, risk-adjustment models, and ICD-10/CPT coding structures.
Staff Education: Train physicians, nurses, and allied health staff on compliant and thorough record-keeping practices.
Quality Metrics: Track outcomes data and quality indicators to support accurate institutional reporting and resource utilization.
Tamil candidates only
Chennai Candidates and Freshers only
Compensation: 402,760.92 - 652,447.47 per year
Benefits
Food provided
Work Location: In person .
