Clinical Documentation Improvement Specialist

Responsibilities

• Review inpatient and outpatient medical records to ensure documentation is complete, accurate, and compliant.
• Identify gaps, inconsistencies, or missing clinical information through concurrent and retrospective chart reviews.
• Issue compliant queries to physicians for clarification of diagnoses, procedures, or clinical conditions.
• Collaborate with coding teams to ensure proper DRG assignment and support medical necessity, SOI, and ROM.
• Assist in reducing denials, revenue leakage, and improving reimbursement accuracy.
• Educate physicians and clinical staff on documentation best practices, ICD-10, and DRG requirements.
• Track CDI KPIs, including documentation completeness, query rates, and denial trends.
• Participate in internal audits and quality assurance initiatives to ensure adherence to regulatory standards.

Requirements

• Bachelor’s degree in Nursing, Health Information Management, or a related field.
• Minimum 2 years of experience in Clinical Documentation Improvement (CDI).
• Minimum 4 years of medical coding experience specifically in Abu Dhabi.
• Certified Medical Coder designation.
• Strong knowledge of ICD-10, CPT, and DRG systems.
• Proficiency in medical terminology and disease processes.

Preferred Qualifications

• Clinical background such as Registered Nurse (RN), coder, or case manager.
• CCDS (Certified Clinical Documentation Specialist) certification.
• CDIP (Clinical Documentation Improvement Practitioner) certification.

About the Company

M42 delivers comprehensive healthcare services across the full continuum of care, from primary care to advanced specialty treatments. Leveraging cutting-edge health technologies and precision medicine, M42 ensures the highest standards of effectiveness and patient-centered outcomes. With a global presence spanning more than 480 facilities in 27 countries, M42 is uniquely positioned to redefine the future of healthcare on a global scale.