International CDI/Coding Consultant

This is a fully remote position, open to applicants in United Arab Emirates (UAE).

📋 Description

• Performing retrospective reviews of charts (both inpatient and outpatient) to evaluate the precision, completeness, and specificity of clinical documentation.

• Utilizing knowledge of ICD-10 code sets, procedure coding, and DRG classification systems to identify gaps in documentation and coding.

• Leveraging medical terminology and reviewing procedures to pinpoint opportunities for enhancing clinical documentation.

• Observing physicians, coders, and Clinical Documentation Improvement (CDI) staff to gain insight into current workflows and documentation practices.

• Conducting interviews with key stakeholders (such as the CDI team, coding personnel, clinicians, and department heads) to gather insights on existing documentation issues.

• Assessing the effectiveness of hospital CDI processes and identifying potential areas for enhancement.

• Creating structured queries and providing feedback where clarification or additional documentation is required.

• Compiling audit results into concise, actionable reports that include identified gaps, risks, and recommendations.

• Leading knowledge transfer sessions to educate client teams on documentation best practices and compliance.

• Collaborating with the project management team to ensure consistency and quality throughout project engagements.

• Upholding strict confidentiality and data security while handling patient records and hospital information.

• Participating in the aggregation of data trends and audit findings to prepare summary reports for management and executives.

• Attending meetings with key stakeholders to review findings and discuss significant recommendations.

⛳️ Requirements

• An Associate's Degree or higher in nursing (BSN preferred), medicine, paramedical sciences, or a related clinical field is essential, or a degree in Health Information Management (RHIA, RHIT, or other coding certification).

• A valid CDI Certification (CCDS, CDIP, or equivalent) is preferred, along with a minimum of three (3+) years of experience in a CDI or coding-related role within a hospital or health system.

• At least 3 years of experience in Clinical Documentation Integrity (CDI) or clinical coding.

• A strong understanding of ICD-10 coding classification, DRG methodologies, clinical coding principles, and coding guidelines.

• Experience in reviewing and querying clinical documentation.

• Ability to conduct structured interviews and observe workflows with hospital staff.

• Proficiency in drafting audit summaries and presenting findings in a professional manner.

• Knowledge and experience in navigating computer applications, including abstracting and encoding software, DRG grouper software, and Hospital Information Systems (HIS).

• Fluency in both written and spoken English.

• Proficiency in using the Microsoft Office suite.

🏝️ Benefits

• Health insurance.

• 401(k) matching.

• Flexible working hours.

• Paid time off.

• Remote work options.

• Professional development opportunities.