Job Description
Are you a detail-oriented Clinical Documentation Improvement (CDI) Specialist with a passion for quality assurance and auditing? Join Nezda Technologies as a CDI Specialist / QA / Auditor and make a tangible impact on patient care and healthcare documentation accuracy. Work from the comfort of your home while enjoying a competitive salary and the stability of a full‑time role.
In this pivotal position, you will identify quality‑of‑care issues through meticulous documentation reviews, collaborate with clinical teams to resolve discrepancies, and ensure compliance with regulatory standards. You will be the bridge between clinical documentation and accurate reimbursement, helping healthcare providers maintain the highest standards.
At Nezda Technologies, we value expertise, integrity, and a proactive mindset. You will be part of a dynamic, remote team that supports your professional growth and provides the tools you need to succeed. If you are ready to elevate your career in healthcare quality and CDI, we want to hear from you!
Responsibilities
- Review and analyze clinical documentation to identify gaps, inconsistencies, and quality‑of‑care issues.
- Collaborate with physicians, nurses, and coding teams to clarify diagnoses and ensure accurate documentation.
- Conduct regular audits of medical records to verify compliance with ICD‑10 coding guidelines and regulatory requirements.
- Provide feedback and education to clinical staff on documentation best practices and CDI principles.
- Generate detailed reports on documentation quality trends, query rates, and audit findings for management.
- Stay current with changes in healthcare regulations, reimbursement policies, and CDI methodologies.
- Participate in process improvement initiatives to enhance documentation accuracy and clinical data integrity.
- Serve as a subject matter expert for internal and external audits, supporting resolution of complex documentation issues.
Qualifications
- Registered Nurse (RN) or equivalent clinical licensure; Certified Clinical Documentation Specialist (CCDS) or CDIP preferred.
- Minimum 3 years of experience in clinical documentation improvement, quality assurance, or healthcare auditing.
- Strong knowledge of ICD‑10‑CM/PCS coding systems, MS‑DRG, APR‑DRG, and clinical documentation requirements.
- Proven ability to perform detailed medical record reviews and communicate findings effectively.
- Excellent written and verbal communication skills in English (additional Filipino language is a plus).
- High level of analytical thinking, problem‑solving, and attention to detail.
- Self‑motivated and comfortable working independently in a remote environment.
- Proficiency with electronic health record (EHR) systems and MS Office applications.