874 Clinical Documentation jobs in India

Thryve Digital Health LLP is an emerging global healthcare partner that delivers strategic innovation, expertise, and flexibility to its healthcare partners. Being a US healthcare conglomerate captive, we have direct access to deeper insights that help us accelerate our learning process and keeps us ahead of the curve. Thryve delivers next-generation solutions that enable our healthcare partners to provide positive experiences to their consumers.

Our global collaborative of healthcare, operations, and IT experts creates innovative and sustainable processes for our clients, which keeps the ever-evolving consumers engaged and assists them in managing the future of their healthcare better. We recognize that our people are our strength and the diverse talents they bring to our global workforce are directly linked to our success. Thryve is an equal opportunity employer and places a high value on integrity, diversity, and inclusion in the organization. We do not discriminate on the basis of any protected attribute. For more information about the organization, please visit

Job Title: Senior Clinical Documentation Improvement (CDI) Specialist

Department: Revenue Cycle Management/Clinical Documentation Improvement

Reports To: CDI Manager/Director

Location: Chennai/Hyderabad

Summary:

The Senior CDI Specialist is responsible for leading clinical documentation improvement efforts to ensure accurate and complete medical record documentation that supports appropriate coding, reimbursement, and quality reporting. This role requires expertise in clinical documentation requirements, coding guidelines, and regulatory standards. The Senior CDI Specialist performs comprehensive medical record reviews, collaborates with physicians and other healthcare providers, provides education and training, and serves as a resource for the CDI team.

Key Responsibilities:

Medical Record Review:

• Conduct concurrent and retrospective reviews of inpatient and outpatient medical records to identify opportunities for documentation improvement.
• Evaluate the accuracy and completeness of clinical documentation to ensure it reflects the patient's condition, treatment, and outcomes.
• Identify discrepancies, inconsistencies, and missing information in the medical record.
• Analyze documentation to determine the principal diagnosis, comorbidities, and complications.

Physician Collaboration and Education:

• Communicate with physicians and other healthcare providers to clarify documentation and obtain additional information.
• Provide education and training to physicians and other healthcare providers on documentation requirements, coding guidelines, and regulatory standards.
• Conduct one-on-one education sessions with physicians to address specific documentation deficiencies.
• Develop and deliver educational materials, presentations, and workshops on CDI topics.

Coding and Reimbursement:

• Ensure that documentation supports accurate coding and billing practices.
• Collaborate with coding staff to resolve coding discrepancies and documentation issues.
• Understand the impact of documentation on reimbursement and DRG (Diagnosis Related Group) assignment.
• Stay current on changes in coding guidelines (ICD-10, CPT, HCPCS) and reimbursement policies.

Data Analysis and Reporting:

• Collect and analyze data related to CDI activities, including query rates, physician response rates, and documentation improvement metrics.
• Prepare reports and presentations on CDI performance and trends. Identify opportunities to improve CDI processes and outcomes.
• Participate in quality improvement initiatives and performance improvement projects.

Regulatory Compliance:

• Ensure compliance with all applicable regulatory requirements, including HIPAA, CMS (Centers for Medicare & Medicaid Services), and Joint Commission standards.
• Stay current on changes in regulatory requirements and guidelines related to clinical documentation and coding.
• Participate in internal audits and external reviews of clinical documentation.

Team Leadership and Mentorship:

• Serve as a mentor and resource for junior CDI Specialists.
• Provide guidance and support to the CDI team on complex cases and documentation challenges.
• Assist in training new team members on CDI processes and procedures.
• Participate in team meetings and contribute to the development of CDI strategies.

System Proficiency:

• Utilize electronic health record (EHR) systems and CDI software to manage medical record reviews and documentation queries.
• Maintain accurate and up-to-date information in CDI tracking systems.

Qualifications, Experience & Skills:

• Registered Nurse (RN), Certified Coding Specialist (CCS), Certified Clinical Documentation Specialist (CCDS), or other relevant clinical or coding certification required.
• Bachelor’s degree in science, Pharma, Nursing, Health Information Management, or a related field preferred.
• Minimum of 5-7 years of experience in clinical documentation improvement, coding, or related healthcare field.
• Strong knowledge of medical terminology, anatomy and physiology, and disease processes.
• Experience working with electronic health record (EHR) systems.
• Excellent communication and interpersonal skills.
• Strong analytical and problem-solving abilities.
• Ability to work independently and as part of a team.
• Excellent organizational and time-management skills.
• Proficiency in using Microsoft Office Suite.

Certifications:

• Required: RN, CCS, CCDS, or other relevant clinical or coding certification.
• Experience with EPIC preferred but not mandatory
• Both Hospital and Professional CDI experience preferred
• Flexible to work from Office all 5 days in the week

Thryve Digital Health LLP is an emerging global healthcare partner that delivers strategic innovation, expertise, and flexibility to its healthcare partners. Being a US healthcare conglomerate captive, we have direct access to deeper insights that help us accelerate our learning process and keeps us ahead of the curve. Thryve delivers next-generation solutions that enable our healthcare partners to provide positive experiences to their consumers.

Our global collaborative of healthcare, operations, and IT experts creates innovative and sustainable processes for our clients, which keeps the ever-evolving consumers engaged and assists them in managing the future of their healthcare better. We recognize that our people are our strength and the diverse talents they bring to our global workforce are directly linked to our success. Thryve is an equal opportunity employer and places a high value on integrity, diversity, and inclusion in the organization. We do not discriminate on the basis of any protected attribute. For more information about the organization, please visit

Job Title: Senior Clinical Documentation Improvement (CDI) Specialist

Department: Revenue Cycle Management/Clinical Documentation Improvement

Reports To: CDI Manager/Director

Location: Chennai/Hyderabad

Summary:

The Senior CDI Specialist is responsible for leading clinical documentation improvement efforts to ensure accurate and complete medical record documentation that supports appropriate coding, reimbursement, and quality reporting. This role requires expertise in clinical documentation requirements, coding guidelines, and regulatory standards. The Senior CDI Specialist performs comprehensive medical record reviews, collaborates with physicians and other healthcare providers, provides education and training, and serves as a resource for the CDI team.

Key Responsibilities:

Medical Record Review:

• Conduct concurrent and retrospective reviews of inpatient and outpatient medical records to identify opportunities for documentation improvement.
• Evaluate the accuracy and completeness of clinical documentation to ensure it reflects the patient's condition, treatment, and outcomes.
• Identify discrepancies, inconsistencies, and missing information in the medical record.
• Analyze documentation to determine the principal diagnosis, comorbidities, and complications.

Physician Collaboration and Education:

• Communicate with physicians and other healthcare providers to clarify documentation and obtain additional information.
• Provide education and training to physicians and other healthcare providers on documentation requirements, coding guidelines, and regulatory standards.
• Conduct one-on-one education sessions with physicians to address specific documentation deficiencies.
• Develop and deliver educational materials, presentations, and workshops on CDI topics.

Coding and Reimbursement:

• Ensure that documentation supports accurate coding and billing practices.
• Collaborate with coding staff to resolve coding discrepancies and documentation issues.
• Understand the impact of documentation on reimbursement and DRG (Diagnosis Related Group) assignment.
• Stay current on changes in coding guidelines (ICD-10, CPT, HCPCS) and reimbursement policies.

Data Analysis and Reporting:

• Collect and analyze data related to CDI activities, including query rates, physician response rates, and documentation improvement metrics.
• Prepare reports and presentations on CDI performance and trends. Identify opportunities to improve CDI processes and outcomes.
• Participate in quality improvement initiatives and performance improvement projects.

Regulatory Compliance:

• Ensure compliance with all applicable regulatory requirements, including HIPAA, CMS (Centers for Medicare & Medicaid Services), and Joint Commission standards.
• Stay current on changes in regulatory requirements and guidelines related to clinical documentation and coding.
• Participate in internal audits and external reviews of clinical documentation.

Team Leadership and Mentorship:

• Serve as a mentor and resource for junior CDI Specialists.
• Provide guidance and support to the CDI team on complex cases and documentation challenges.
• Assist in training new team members on CDI processes and procedures.
• Participate in team meetings and contribute to the development of CDI strategies.

System Proficiency:

• Utilize electronic health record (EHR) systems and CDI software to manage medical record reviews and documentation queries.
• Maintain accurate and up-to-date information in CDI tracking systems.

Qualifications, Experience & Skills:

• Registered Nurse (RN), Certified Coding Specialist (CCS), Certified Clinical Documentation Specialist (CCDS), or other relevant clinical or coding certification required.
• Bachelor’s degree in science, Pharma, Nursing, Health Information Management, or a related field preferred.
• Minimum of 5-7 years of experience in clinical documentation improvement, coding, or related healthcare field.
• Strong knowledge of medical terminology, anatomy and physiology, and disease processes.
• Experience working with electronic health record (EHR) systems.
• Excellent communication and interpersonal skills.
• Strong analytical and problem-solving abilities.
• Ability to work independently and as part of a team.
• Excellent organizational and time-management skills.
• Proficiency in using Microsoft Office Suite.

Certifications:

• Required: RN, CCS, CCDS, or other relevant clinical or coding certification.
• Experience with EPIC preferred but not mandatory
• Both Hospital and Professional CDI experience preferred
• Flexible to work from Office all 5 days in the week

• Process non-clinical transactions with a high degree of accuracy

• The process involves viewing documents on the screen, identifying, and capture of the right information on the right fields. The document types include prescriptions, lab reports, and imaging documents.

To be considered for this position, applicants need to meet the following qualification criteria:

• Graduates in any non-engineering courses. People who have completed a 3-year diploma course may also apply

• Basic typing (20 WPM) and good communication skills

• Willingness to work in different shift

• Preference will be given to healthcare BPO professionals with experience in non-voice processes, good typing, and interpersonal skills, along with a good overall performance track record

• We are also hiring fresh graduates as Assistant Client Partners.

Role : Associate Manager - Clinical Data Management

Location : Chennai, Tamil Nadu

Experience : 10+ Years

Requirements:

• 10-12 years of experience in clinical trial/data management and data operations.
• Minimum 4-5 years of people management (preferred) experience with proven supervisory
• skills.
• Extensive experience with CTMS platforms (CRIO, RT CTMS, Veeva Vault CTMS, or similar).
• Strong background in EDC systems management and clinical data operations.
• Experience in pharmaceutical, biotechnology, or CRO environment across multiple
• therapeutic areas.

Technical Expertise

• CTMS configuration and administration skills (Having knowledge in CRIO is an advantage).
• Deep knowledge of EDC platforms and system integrations.
• Strong understanding of regulatory requirements (HIPPA, FDA, EMA, ICH-GCP).
• Experience with electronic systems validation and 21 CFR Part 11 compliance.

Key Accountabilities

* Under the direction of the CDM Lead or delegate, performs data management tasks according to applicable SOPs (standard operating procedures) and processes. These activities may include the following categories:

Data Review

* Performs data review of clinical trial data, including query management

* Performs reconciliation review of external data against EDC data

* May assist in creating study documents or assist in running study reports and metrics

* Performs additional review activities for interim and final database locks as needed.

Documentation & Filing

* Files study documentation in electronic Trial Master File (eTMF) and department project files.

* Performs periodic quality review of eTMF documents.

* Assists with taking meeting minutes and documenting/tracking study data management activities.

* Performs data archival activities.

* Performs inspection readiness activities and supports CDM team during internal and regulatory inspections

Data Collection Systems

* May support the set-up and testing of study data collection tools.

Additional Activities

* Assists with quality review of above activities performed by the CRO, as needed.

* Ensure compliance with own Learning Curricula, corporate and/or GXP requirements.

* Performs other duties as assigned.

Educational Qualifications

* Associate or Bachelor's Degree preferred

Experience

* Ideally 1 or more years relevant work experience, or equivalent combination of training and experience.

* Familiar with electronic data collection systems

* Preferred knowledge of data management best practices & technologies as applied to clinical trials.

* Preferred knowledge of FDA and ICH regulations and industry standards applicable to data capture and data management process.

Special Skills/Abilities

* Strong attention to detail, and organizational skills

* Good time management skills

* Quick learner and comfortable learning new technologies and systems

* Good knowledge of office software (Microsoft Office).

Behavioral Competencies

* Is comfortable with ambiguity.

* Excellent teamwork, organizational, interpersonal, conflict resolution and problem-solving skills.

Role: Clinical Data specialist

Skill: CDM, Rave

Mode: Hybrid

Experience: 2-5 years in Clinical Data management

Job Location: Kochi/Kolkata/Bangalore

Educational Qualification: Any life science graduate

Job Overview:

Provide basic and some comprehensive data management expertise to the Clinical Data Management (CDM) team to provide efficient, quality data management products that meet customer needs. May also undertake team leadership activities under the supervision of the Data Operations Coordinator (DOC), Data Team Lead (DTL), or Functional Manager.

Essential Functions

• Serve as a Data Operations Coordinator (DOC) for one protocol with less then 5 operations staff (excludes DE) or 15+ easy to moderately complex central laboratory studies, or serve in a leadership role in a specific data management task (e.g., coder, tester or database designer for technologies that don't require extensive programming expertise) with guidance.
• May serve in the role of back-up to a DOC or DTL.
• May conduct data review.
• May write and resolve data clarifications.
• May lead database audit team.
• May develop and test databases and edit specifications.
• May perform testing of programming.
• May perform clinical data coding. Understand and comply with core operating procedures and working instructions. Meet objectives as assigned. Develop and maintain good communications and working relationships with CDM team."

Qualifications

• Bachelor's Degree Clinical, biological , or related field Req
• Equivalent combination of education, training and experience in lieu of degree.