Clinical Documentation Improvement Officer

Sheikh Shakhbout Medical City

The Clinical Documentation Improvement Officer will work collaboratively with physicians, coders, and clinical staff to enhance the quality of clinical documentation. The role involves reviewing medical records, identifying documentation gaps, and providing education to clinicians to ensure that the patient s clinical picture is fully and accurately captured. The ideal candidate will have strong knowledge of UAE healthcare documentation standards, coding principles, and hospital quality requirements.

• Bachelor s degree in Nursing, Health Information Management, or a related clinical field.
• Certified Clinical Documentation Specialist (CCDS) or equivalent preferred.
• Minimum 3 5 years of experience in clinical documentation, medical coding, or quality management within a hospital in the UAE.
• Strong understanding of ICD-10 coding and UAE DRG systems.
• Familiarity with EMR systems (e.g., Cerner, Epic, TrakCare).
• Strong analytical, auditing, and reporting skills.
• Excellent communication and clinical knowledge.
• Ability to educate and collaborate effectively with multidisciplinary teams.
• High attention to detail and confidentiality.
• Proficiency in English; Arabic is an advantage

• Review inpatient and outpatient medical records to ensure accurate and complete clinical documentation.
• Identify documentation deficiencies and communicate with physicians to clarify or enhance patient records.
• Collaborate with the coding and billing teams to ensure documentation supports correct ICD and CPT coding.
• Conduct concurrent and retrospective reviews to improve data accuracy and hospital reimbursement.
• Provide education and feedback to physicians and clinical staff on best practices in clinical documentation.
• Monitor compliance with UAE health authority (DOH/DHA/MOH) documentation and coding standards.
• Support hospital accreditation and quality initiatives by maintaining accurate medical record documentation.
• Prepare reports and analyses on documentation trends, audit results, and performance improvement areas.
• Participate in CDI policy development and process improvement initiatives.