43 Medical 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

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

About Us

Proudly Australian, Sonic HealthPlus is the largest provider of corporate medicine in the country. With a national network of wholly owned metropolitan and remote clinics, we deliver Occupational Health, General Practice and integrated medical, paramedical and wellness services to both large and small corporate and community groups.

About The Role

Are you an organised, detail-oriented professional with a passion for supporting healthcare operations? We’re looking for a Medical Coordinator to join our collaborative team, playing a vital role in guiding Australian Defence Force (ADF) candidates through the medical and psychological components of the Defence Force Recruiting (DFR) process.

As a Medical Coordinator, you’ll be part of a supportive team dedicated to ensuring an efficient and positive experience for every candidate. Working from our Bourke Street Clinic (Wurundjeri people of the Kulin Nation) in Victoria, you will manage clinical records, coordinate appointments, monitor service delivery, and provide critical logistical and administrative support to our team of Doctors, Nurses, and Psychologists.

You’ll report directly to the DFR Regional Practice Manager and help ensure the seamless delivery of high-quality healthcare administration

Key Responsibilities

· Liaising with ADF candidates throughout their recruitment process

· Booking and managing medical and psychological appointments

· Coordinating with clinicians and medical professionals

· Maintaining accurate candidate records and handling data entry

· Performing general administrative duties

About You

You’re proactive, organised, and driven to provide outstanding service. You thrive in healthcare or medical environments and enjoy being the backbone of efficient clinical support.  

Essential Requirements:

• Strong administration and customer service skills
• Previous experience in a healthcare or medical setting
• High attention to detail and commitment to quality service
• Excellent interpersonal and communication skills
• Current CPR Certificate and Working with Children Check (or willingness to obtain – support available)
• Australian Citizenship (mandatory for AGSVA Baseline Security Clearance eligibility)

We strongly encourage veterans and individuals with Defence Force experience to apply.

Why Join Us?

• Rewarding opportunity
• Work/life balance
• Reputable national healthcare provider (part of the global Sonic Healthcare)
• Extensive training and career development opportunities (Sonic HealthPlus is an RTO)
• Paid parental leave
• Discounted gym membership
• Discounted health insurance options
• Novated Leasing
• Discounted fees for various medical services e.g. pathology, radiology and travel health
• Employee Assistance Program
• Focus on corporate social responsibility e.g. fundraising, supporting community events

How To Apply

As part of our pre-employment process, preferred candidates must provide a National Police Clearance conducted within the last 3 months.

Short listing for this position will commence immediately. You are encouraged to apply promptly as applications will close when suitable applicants are obtained.

Diversity, Equity And Inclusion

At Sonic HealthPlus, we embrace a diverse mix of minds and backgrounds, creating a supportive environment where every voice is valued. Our commitment to gender equity fosters a safe, respectful, and welcoming space for all. We honour the unique experiences of veterans and current serving members of the Australian Defence Force and their families, whose military backgrounds enrich our workplace. 

We encourage applications from individuals of all ages, cultures (including Aboriginal and Torres Strait Islander peoples), abilities, sexual orientations, religions and gender identities, reflecting the vibrant diversity of our communities. As an Equal Opportunity Employer, we value social and cultural diversity and strongly encourage Aboriginal and Torres Strait Islander peoples to apply. Sonic HealthPlus prioritises accessibility and we are happy to adjust our recruitment processes to support all candidates. If you require more information about our diversity, equity and inclusion framework or would like assistance with your application, please contact us at ***.

Job Description: Outpatient Clinical Documentation Improvement (CDI) Specialist:

On-site, WFO.

Minimum Education Qualification:

Bachelor of Medicine; Bachelor of Surgery; Registered Nurse; Master/ Bachelor of Pharmacy; Bachelor of Science.

The only qualification I was forced to add was a Bachelor of Science with 5+ years of HCC coding experience.

Minimum Experience:

Minimum of 5 years of experience with a US Hospital inpatient or outpatient clinical documentation improvement and risk adjustment medical coding.

Strong knowledge of outpatient coding methodologies (ICD-10-CM, CPT, HCPCS) and risk adjustment models.

Minimum Certification:

Certified Risk Adjustment Coder (CRC).

Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP).

Certified Professional Coder (CPC) or Certified Coding Specialist (CCS).

Why Join Us? This role offers a unique opportunity to make a meaningful impact on healthcare quality and reimbursement accuracy. Join a collaborative and supportive team committed to excellence in clinical documentation, compliance, and patient outcomes at Doctus.

Take the Next Step in Your CDI Career: Apply now and play a key role in shaping the future of clinical documentation integrity!