job description
Join Epsilon Group Services as a USRN Clinical Documentation Improvement (CDI) Specialist and play a pivotal role in enhancing healthcare outcomes through accurate and comprehensive clinical documentation. This position is ideal for US-licensed Registered Nurses (USRN) with acute hospital bedside experience, offering the opportunity to leverage your clinical expertise in a dynamic, remote-friendly environment based in Bali, Indonesia.
As a CDI Specialist, you will collaborate with healthcare providers to ensure medical records accurately reflect the severity of illness, risk of mortality, and complexity of care. Your work will directly impact reimbursement accuracy, regulatory compliance, and patient care quality. This role combines clinical knowledge, analytical skills, and attention to detail to drive improvements in healthcare documentation.
Epsilon Group Services is committed to fostering a supportive and innovative work culture, providing competitive compensation, professional growth opportunities, and the flexibility to work from Bali’s most vibrant locations.
Responsibility
- Review and analyze medical records to identify gaps in clinical documentation that impact coding, billing, and quality metrics.
- Collaborate with physicians, nurses, and coding teams to clarify and improve documentation of diagnoses, procedures, and patient care.
- Ensure compliance with MS-DRG, APR-DRG, and other regulatory standards (e.g., CMS, Joint Commission).
- Educate healthcare providers on best practices for accurate and thorough clinical documentation.
- Monitor and report on CDI program performance, including query rates, case mix index (CMI), and denial trends.
- Utilize CDI software and EHR systems to track and document findings efficiently.
- Stay updated on evolving healthcare regulations, coding guidelines (ICD-10-CM/PCS), and industry best practices.
- Participate in interdisciplinary team meetings to address documentation deficiencies and process improvements.
Qualifications
- Active US Registered Nurse (USRN) license in good standing (required).
- Minimum 2+ years of acute hospital bedside experience in medical-surgical, ICU, ER, or other high-acuity settings.
- Proven experience in Clinical Documentation Improvement (CDI) or a related role (preferred).
- Strong understanding of medical terminology, ICD-10-CM/PCS, and DRG methodologies.
- Excellent communication, critical thinking, and interpersonal skills to engage with healthcare providers.
- Proficiency in EHR systems (e.g., Epic, Cerner) and CDI software (e.g., 3M, Nuance).
- Ability to work independently in a remote or hybrid setting with a stable internet connection.
- Familiarity with CMS guidelines, HIM standards, and revenue cycle management is a plus.