Clinical Documentation Improvement Specialist

Overview 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, we ensure the highest standards of effectiveness, efficiency, and patient-centered outcomes. With a global presence spanning more than 480 facilities in 27 countries and a dedicated workforce of over 20,000 professionals, M42 is uniquely positioned to redefine the future of healthcare on a global scale.

Healthpoint is a multi-specialty hospital offering a wide range of primary and specialty care services. Based in Abu Dhabi, it serves patients from the UAE and around the world. Committed to elevating patient care to the highest standards, Healthpoint has been recognized by numerous renowned international awarding and accrediting bodies.

This role is responsible for ensuring the accuracy, completeness, and compliance of clinical documentation in patient medical records. The role supports quality of care, regulatory compliance, and optimal reimbursement by working closely with physicians, coders, and clinical teams.

Responsibilities

• Clinical Documentation Review
• Review inpatient and outpatient medical records to ensure documentation is complete, accurate, and compliant.
• Identify gaps, inconsistencies, or missing clinical information.
• Conduct concurrent and retrospective chart reviews for documentation improvement opportunities.
• Physician Query & Engagement
• Issue compliant queries to physicians for clarification of diagnoses, procedures, or clinical conditions.
• Collaborate with physicians, nurses, and case management teams to ensure accurate representation of patient care.
• Coding & Revenue Cycle Support
• Work closely with coding teams to ensure proper DRG assignment and coding accuracy.
• Ensure documentation supports medical necessity, severity of illness (SOI), and risk of mortality (ROM).
• Assist in reducing denials and improving reimbursement accuracy
• Support reduction of medical necessity denials and revenue leakage
• Perform daily review of revenue optimization progress
• Coordinate closely with clinical, coding, and billing teams
• Education & Training
• Educate physicians and clinical staff on documentation best practices and regulatory requirements.
• Provide training on ICD-10, DRG documentation, and coding compliance.
• Share feedback on documentation deficiencies and improvement opportunities.
• Compliance & Audit
• Ensure adherence to regulatory standards, coding guidelines (ICD-10, CPT), and payer requirements.
• Participate in internal audits, documentation reviews, and quality assurance initiatives.
• Maintain compliance with organizational clinical documentation policies
• Data Analysis & Reporting
• Track CDI KPIs such as documentation completeness, query rates, and denial trends.
• Analyze trends to identify areas for improvement and provide recommendations.
• Prepare reports and dashboards for leadership review.

Key Skills & Competencies

• Strong knowledge of medical terminology, disease processes, and coding systems (ICD-10, CPT, DRG)
• Analytical skills to identify documentation gaps
• Excellent communication and physician engagement skills
• Knowledge of healthcare regulations and audit requirements
• Detail-oriented with strong problem-solving ability

Qualifications

• Bachelor’s degree in Nursing, Health Information Management, or related field

• Clinical background (e.g., RN, coder, case manager) preferred

• Minimum 2 years of experience in Clinical Documentation Improvement

• Minimum 4 years of medical coding experience in Abu Dhabi

• Certified Medical Coder

• Other certifications preferred:

• CCDS (Certified Clinical Documentation Specialist)

• CDIP (Clinical Documentation Improvement Practitioner)