clinical documentation specialist

Cliniqon RCM Pvt Ltd

We are looking for a detail-oriented and highly motivated Clinical Documentation Auditor to join our growing team in Kochi. In this role, you will play a key part in ensuring the accuracy, clarity, and compliance of clinical documentation across medical records.Job Responsibilities:<ul><li>Review clinical documentation in medical records for accuracy, completeness, and clarity.</li><li>Audit charts to ensure compliance with industry standards, regulatory requirements, and organizational policies.</li><li>Identify documentation gaps and provide feedback to healthcare providers and coding staff.</li><li>Ensure all diagnoses and procedures are clearly and accurately documented to support correct coding.</li><li>Prepare audit reports with findings, recommendations, and corrective actions.</li><li>Conduct regular internal audits to assess documentation practices and maintain quality standards.</li><li>Collaborate with clinical teams to improve documentation processes and support quality improvement initiatives.</li></ul>Qualifications:<ul><li>Completion of a Nursing degree (B.Sc Nursing, GNM, or equivalent) is mandatory.</li><li>Must be a Registered Nurse (RN) with valid credentials.</li><li>Prior experience in medical transcription or clinical documentation review is required.</li><li>A minimum of 1-3 years of experience in clinical documentation, chart review, medical scribing, auditing, or a related role within a clinical or BPO environment.</li></ul>Job Types: Full-time, PermanentPay: &#8377;21,000.00 - &#8377;35,000.00 per monthBenefits:<ul><li>Food provided</li><li>Health insurance</li><li>Provident Fund</li></ul>Work Location: In person

Clinical Documentation Auditor

Elico Ltd

Role Description : The Certified Medical Coder will be responsible for accurately coding medical records, ensuring compliance with coding guidelines, and optimizing revenue.Daily tasks include reviewing and analyzing patient records, assigning appropriate codes, and collaborating with healthcare professionals to clarify information.The role also involves monitoring coding accuracy and staying updated with coding regulations and standards.Location : HyderabadEducation : Bachelor&rsquo;s degree in Nursing, Allied Health, Life Sciences, or a related healthcare fieldQualifications : <ul><li>CPC, CCS certified or equivalent credential.</li><li>2&ndash;5 years of experience in clinical documentation review, medical coding, utilization review, or related healthcare documentation work.</li><li>Strong understanding of medical terminology, disease processes, and healthcare documentation standards.</li><li>Excellent analytical, written communication, and summarization skills.</li><li>Familiarity with EHR/EMR systems (e.g., Epic, Cerner, Meditech) and Microsoft Office tools.</li></ul>Responsibilities : <ul><li>Review and evaluate medical records, progress notes, discharge summaries, and other clinical documentation for accuracy and completeness.</li><li>Prepare concise and comprehensive clinical summaries highlighting key diagnoses, treatments, medications, and outcomes.</li><li>Ensure documentation aligns with coding, billing, and compliance requirements (e.g., ICD-10, CPT, CMS, HIPAA).</li><li>Identify gaps, inconsistencies, or missing information in clinical documentation and escalate for clarification or correction.</li><li>Support preauthorization, claims, and medical necessity reviews by providing clinical context and supporting summaries.</li><li>Collaborate with physicians, nurses, coders, and case managers to maintain high-quality clinical documentation.</li><li>Maintain confidentiality and data integrity in accordance with HIPAA and organizational policies.</li><li>Participate in internal audits, training sessions, and process improvement initiatives related to documentation standards.</li></ul>Job Types: Full-time, PermanentPay: &#8377;360,000.00 - &#8377;540,000.00 per yearWork Location: In person

Certified Medical Coder

CHRISTUS Health

<div>Description 
Summary:
This position is responsible for facilitating improvement in the overall quality and completeness of the medical record documentation. The clinical documentation RN will provide support and expertise through comprehensive assessment and review of inpatient medical records. The clinical documentation RN will facilitate accurate DRG assignment and obtain appropriate documentation through extensive interaction with physicians, patient caregivers and health information management coding staff to ensure that reimbursement is received for the level of services rendered to the patients.
Responsibilities:
<ul><li>Analyzes clinical status of patient, current treatment plan and past medical history and identifies potential gaps in physician documentation</li><li>
Communicates with attending physician either verbally or through written methodology to validate observations and suggest additional and/or more specific documentation</li><li>
Maintains positive open communication with physicians, nursing and all other disciplines involved in the care of the patient</li><li>
Works closely with HIM Coding staff to assure documentation of discharge diagnosis and any co-existing co-morbidities are a complete reflection of the patient's clinical status and care</li><li>
Maintains an electronic DRG worksheet to assist coders on identifying all documented diagnosis and procedures</li><li>
Updates DRG worksheet to reflect any changes inpatient status/procedure/treatment and confers with the physician to finalize diagnosis</li><li>
Consistently meets established productivity targets for record review</li><li>
Designs and implements in collaboration with physician leadership specific tools to support medical record physician documentation</li><li>
Develops and implements plans for both formal and informal education of physician, nursing, and other clinical staff on clinical documentation opportunities, coding and reimbursement as well as performance improvement methodologies</li><li>
Assists in collection and organization of data for analysis by appropriate medical and hospital committees</li><li>
Identifies strategies for sustained work process changes that facilitate complete, accurate clinical documentation</li><li>
Demonstrates competence to perform assigned responsibilities is a manner that meets the population-specific and developmental needs of the members served by the department</li><li>
Appropriately adapts assigned assessment, treatment, and/or service methods to accommodate the unique physical, psychosocial, cultural, age-specific and other developmental needs of each member served</li><li>
Takes personal responsibility to ensure compliance with all policies, procedures and standards as promulgated by state and federal agencies, the hospital, and other regulatory entities</li><li>
Performs all duties in a manner that protects the confidentiality of patients and does not solicit or disclose any confidential information unless it is necessary in the performance of assigned job duties</li><li>
Performs other duties as assigned</li></ul>
Requirements:
<ul><li>Associate's Degree in Nursing</li><li>
RN License in state of employment or compact</li></ul>
Work Schedule: 
5 Days - 8 Hours
Work Type:
Full Time</div>

Clinical Documentation Registered Nurse II - Clinical Documentation Integrity

<div>Description 
Summary:
The Clinical Documentation Registered Nurse collaborates extensively with physicians, nursing staff, other patient caregivers and coding staff to improve the quality and completeness of documentation of care provided and coded for coordination, abstraction and submission of accurate data required by CMS. Facilitates concurrent modifications to clinical documentation to insure commensurate reimbursement of clinical severity and services rendered to patients with a DRG based payer (Medicare, Medicaid). Supports timely, accurate and complete documentation of clinical information used for measuring and reporting physician and facility outcomes. Communicates with and educates all clinical staff concerning accurate and effective clinical documentation.
Responsibilities:
<ul><li>Reviews inpatient medical records for identified payer populations as within one business day of admission and throughout hospitalization to identify opportunities for physician documentation.
</li><li>Analyzes clinical status of patient, current treatment plan, and past medical history and identifies potential gaps in MD documentation and leaves physician query to obtain complete, accurate clinical documentation.
</li><li>Works closely with HIM coding staff to assure documentation of discharge diagnosis and any co-existing co-morbidities is a complete reflection of the patient&rsquo;s clinical status and care</li><li>
Maintain a DRG worksheet to assist coders on identifying all documented POA/HAC, diagnosis and procedures</li><li>
Updates DRG worksheet to reflect any changes to inpatient status/procedure/treatment and confers with the physician to finalize diagnosis.
</li><li>Demonstrates basic knowledge about HIM coding standards and applies to ongoing evaluation of medical record documentation for accuracy of physician documentation to support the acuity of illness.</li><li>
Performs chart review on expired patients to identify severity of illness and risk of mortality for performance improvement activities.</li><li>
Develops and implements plans for both formal and informal education of physician, nursing, and other clinical staff on clinical documentation opportunities, coding and reimbursement as well as performance improvement methodologies.</li><li>
Collaborate with case manager regarding cases with length of stay outside of the expected GMLOS, to ensure documentation identifies severity of illness and maximizes reimbursement potential.</li><li>
Coordinates and assures complete and accurate data collection and validation for public reporting data initiatives for Premier, CMS and JCAHO.</li><li>
Maintains good rapport and cooperative relationships. Approaches conflict in a constructive manner. Helps identify problems, offers solutions, and participates in their resolution.</li><li>
Coordinates with quality department by: providing concurrent review for core measures documentation, providing retrospective chart audits as needed, and educating nursing and medical staff of improvement and current status of quality initiates.</li><li>
Performs follow-up to document physician response to queries. Tracks and trends patterns of physician responses and reports monthly to director.</li><li>
Designs and implements collaboration with physician leadership specific tools to support medical record physician documentation.</li><li>
Review clinical issues with coding staff to assign working DRG&rsquo;s.</li><li>
Work collaboratively with the coding staff to ensure that documentation of discharge diagnoses and co-morbidities are a complete reflection of the patient&rsquo;s clinical status and care.
</li><li>Review final DRG and compare with clinical data gathered to ensure the DRG assigned is appropriated and that all co-morbidities are captured.</li><li>
Communicates with Case Management Director and/or Vice President of Medical Affairs regarding program barriers/success/outcomes of CDI program.
</li><li>Assists in collection and organization of data for analysis by appropriate medical and hospital committees.
</li><li>Consistently meets established productivity targets for record review.
</li><li>Maintain strict confidentiality at all time.</li><li>
Performs other duties as assigned.</li></ul>
Requirements:
<ul><li>Associate's Degree in Nursing</li><li>
RN License in state of employment or compact</li></ul>
Work Schedule: 
PRN
Work Type:
Per Diem As Needed</div>

Clinical Documentation Registered Nurse - Clinical Documentation Integrity

Romeo Staffing Agency

Job description:Job Title: Quality Assurance NurseLocation: Malir, Karachi (near the Airport)Timings: 6 PM &ndash; 3 AM (Monday to Friday)Job Type: Full-TimeCompany: Romeo Staffing Agency (RSA)About the CompanyRomeo Staffing Agency (RSA) provides healthcare staffing and compliance support to U.S.-based home health and hospice agencies. Our Karachi office serves as a back-office support center for clinical documentation, quality assurance, HR, and administrative operations. We are known for our structured work environment, growth opportunities, and collaboration with leading healthcare providers in Michigan and beyond.Position OverviewWe are seeking a Quality Assurance Nurse (QA Nurse) to join our QA and compliance team. The QA Nurse will review and verify clinical documentation submitted by U.S.-based field clinicians to ensure accuracy, completeness, and compliance with agency and CMS standards.Responsibilities<ul><li>Review skilled nursing notes, OASIS assessments, and visit documentation for accuracy and completeness.</li><li>Identify documentation gaps, inconsistencies, or errors and coordinate corrections with the relevant teams.</li><li>Ensure all documentation meets medical necessity and regulatory requirements.</li><li>Maintain documentation logs and prepare QA reports.</li><li>Support ongoing quality improvement initiatives and participate in internal training programs.</li><li>Collaborate with U.S.-based teams to uphold agency documentation and compliance standards.</li></ul>Requirements<ul><li>Bachelor of Science in Nursing (BScN) valid Pakistan Nursing Council (PNC) license.</li><li>Minimum 1 year of experience in nursing, QA, or medical documentation.</li><li>Knowledge of U.S. home health or hospice documentation standards preferred.</li><li>Excellent English communication (written and verbal).</li><li>Strong attention to detail and time management skills.</li><li>Proficient in MS Word, Excel, and EMR systems.</li><li>Willingness to work night shift (6 PM &ndash; 3 AM) to align with U.S. operations.</li></ul>Why Join RSAOpportunity to work with U.S.-based healthcare organizations.Supportive and structured work environment.Professional growth and skill development opportunities.Market-competitive salary.Job Type: Full-timePay: Rs65,000.00 - Rs95,000.00 per monthAbility to commute/relocate:<ul><li>Malir Colony: Reliably commute or planning to relocate before starting work (Required)</li></ul>Education:<ul><li>Bachelor's (Preferred)</li></ul>Experience:<ul><li>Nursing: 1 year (Preferred)</li></ul>Language:<ul><li>English (Required)</li></ul>License/Certification:<ul><li>PNC License (Required)</li></ul>Work Location: In person

QA Nurse

Teksoft Solutions

Job Title: Back-End Support Executive (Clinical Operations) &mdash; Night ShiftLocation: Gulshan-e-Iqbal, Block 4, Karachi (Onsite)Qualification: MBBS requiredAbout the RoleWe support US-based physicians caring for patients in hospitals, Skilled Nursing Facilities (SNF), Assisted Living Facilities (ALF), and home-based/telehealth programs. As a Back-End Support Executive, you will work the night shift to review patient information across multiple EHRs, prepare concise clinical notes, and escalate priority issues to the on-call US doctor in real time (primarily via Google Chat voice/text).Key Responsibilities<ul><li>Chart Review &amp; Data Abstraction</li><li>Review admission notes, progress notes, vitals, I/O, labs, imaging, and orders across different EHRs.</li><li>Track trends in vitals, labs, and test results (e.g., BP/HR/SpO&#8322;, CBC/CMP, troponin, INR, A1c, renal panel).</li><li>Clinical Documentation</li><li>Draft clear clinical notes in the EHR aligned to patient condition and physician directives.</li><li>Add encounter information and update problem lists/medication lists/allergies after physician visits.</li><li>Maintain accurate time-stamped logs of all actions taken and communications sent/received.</li><li>Triage &amp; Escalation</li><li>Prioritize and escalate abnormal findings to the US physician according to the escalation matrix (e.g., critical labs, significant vitals deviation, rapid clinical changes).</li><li>Summarize cases succinctly (chief issue &rarr; pertinent findings &rarr; objective data &rarr; current status &rarr; requested action).</li><li>Communication</li><li>Work directly with US physicians via Google Chat (voice notes + text); capture and implement instructions precisely.</li><li>Coordinate with internal teams to resolve EHR access issues, missing data, or documentation gaps.</li><li>Compliance &amp; Quality</li><li>Adhere to HIPAA/PHI confidentiality, organizational SOPs, and documentation standards.</li><li>Meet SLAs and quality targets for accuracy, completeness, and turnaround time.</li></ul>Required Qualifications &amp; Skills<ul><li>MBBS (mandatory).</li><li>Comfortable working night shifts aligned to US hours.</li><li>Strong grasp of medical terminology, clinical reasoning, and basic interpretation of vitals/labs.</li><li>Excellent written and verbal communication in English; crisp, structured clinical summaries.</li><li>High attention to detail, reliability, and sound decision-making under time constraints.</li><li>Hands-on with EHR systems (any), Google Workspace (Docs/Sheets), and Google Chat.</li><li>Fast, accurate typing; disciplined task tracking and follow-through.</li></ul>Nice to Have<ul><li>Prior experience in clinical operations, hospitalist programs, RPM/CCM, or back-office physician support.</li><li>Familiarity with US payer/clinical workflows and common EHRs (e.g., Epic, PCC, Athena, eCW, Elation, etc.).</li></ul>Shift, Employment Type &amp; Location<ul><li>Shift: Night (US hours) &mdash; exact schedule shared during interviews.</li><li>Type: Full-time, onsite.</li><li>Office: Gulshan-e-Iqbal, Block 4, Karachi.</li></ul>Performance KPIs (what success looks like)<ul><li>Documentation accuracy &amp; completeness.</li><li>Turnaround time from data review to escalation.</li><li>Adherence to escalation matrix and SOPs.</li><li>Communication clarity and responsiveness.</li><li>Compliance (HIPAA/PHI) and zero data-handling incidents.</li></ul>What We Offer<ul><li>Structured onboarding with SOPs, escalation matrix, and EHR workflows.</li><li>Continuous coaching and clear growth paths in clinical operations.</li><li>Market Competitive Salary</li><li>Health Insurance</li><li>Door to Door Pick and Drop for female candidates.</li></ul>How to ApplySend your CV and a short note on relevant experience to career@teksoft.net with subject:<ul><li>Back-End Support Executive (Night Shift) &mdash; MBBS.</li></ul>Job Type: Full-timeApplication Question(s):<ul><li>Expected Salary?</li><li>Comfortable with night shifts? 5PM to 2AM or 6PM to 3AM?</li><li>Any notice period?</li></ul>Work Location: In personExpected Start Date: 15/11/2025

Back-End Support Executive (Clinical Operations) — Night Shift

DallahHealth

<div>
 
 Key Activities:
 
 
 Follow all relevant policies, processes, standard operating procedures, and instructions and ensure work is carried out in a controlled and consistent manner.
 
 
 &bull; Promote the implementation and adherence to relevant policies, processes, and operating procedures to others.
 
 
 &bull; Contribute to the identification of opportunities for continuous improvement of systems, processes, and practices, taking into account leading practices, improvement of department processes, cost reduction, and productivity improvement.
 
 
 &bull; Apply safety, quality, and environmental management policies, procedures, and controls to ensure safety, legislative compliance, delivery of high-quality service, and a responsible environmental attitude.
 
 
 &bull; Build high levels of trust and understanding with key internal and external stakeholders to promote full compliance with industry regulations and promote a broader understanding of Dallah Health&rsquo;s interests and practices.
 
 
 
 
 
 Perform daily checks to ensure that patient medical records are complete, accurate, and in compliance with hospital documentation standards.
 
 
 -Identify deficiencies, incomplete documentation, or errors and communicate with relevant staff or departments to resolve them.
 
 
 -Assist in tracking record completion and delinquency rates.
 
 
 -Ensure that physical or electronic records are properly organized, indexed, and filed according to established procedures.
 
 
 -Assist with chart assembly and document scanning if required by department workflows.
 
 
 -Verify that records contain all necessary clinical documentation for accurate coding.
 
 
 -Communicate with coding teams to clarify documentation details when needed.
 
 
 Process requests for medical records or information release in compliance with privacy laws and hospital policies.
 
 
 -Verify authorization and consent before releasing any patient information to internal or external parties.
 
 
 -Maintain logs and documentation related to release information.
 
 
 -Handle all patient information with strict confidentiality in accordance with MOH and hospital privacy requirements.
 
 
 -Report any potential data breaches or unauthorized access to the HIM Operations Assistant Manager.
 
 
 -Liaise with physicians, nurses, and other departments to resolve documentation or record-related queries.
 
 
 -Support audits or surveys by preparing records and integrity reports as assigned.
 
 
 -Suggest improvements to operational workflows, checklists, or filing processes to enhance HIM service delivery.
 
 
 -Stay updated on changes in HIM standards, privacy laws, and hospital documentation policies.
 
 
 
 
 
 Knowledge and Experience:
 
 
 
 
 
 4&ndash;7 years of relevant HIM or medical records experience in a hospital setting.
 
 
 -Familiarity with MOH standards, data privacy regulations, and CBAHI/JCI accreditation requirements.
 
 
 Education and Certifications:
 
 
 Bachelor&rsquo;s degree in Health Information Management, Health Informatics, or a related field.
 
 
 -Valid registration with the Saudi Commission for Health Specialties (SCFHS) if required
 
 
 SKILLS
 
 
 Strong knowledge of EMR configuration, documentation workflows, and clinical informatics principles.
 
 
 -Sound understanding of coding and clinical documentation requirements.
 
 
 -Effective communication skills to engage clinicians, IT, and administrative teams.
 
 
 -Strong analytical skills for monitoring data quality and driving improvements.
 
 
 -High level of integrity and respect for patient confidentiality.
 
 
 
 
</div>

HIM Operations Senior Specialist

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