Role Overview
Agents Only Technologies Inc. is seeking experienced Health Information Management (HIM) and Clinical Documentation Improvement (CDI) Specialists to support a specialized Medical Record Synthesis project.
In this role, contributors will author training and evaluation scenarios based on complex, multi-encounter patient records and create gold-standard chronological summaries. The work requires accurately synthesizing information across multiple visits, identifying clinically redundant testing, and ensuring that every summary point can be traced back to its source documentation.
This is a Priority 1 expert project requiring strong medical-record review, structured summarization, source attribution, and clinical documentation expertise.
Responsibilities
Key Responsibilities
As a Medical Record Synthesis – HIM / CDI Specialist, you will:
- Author realistic multi-visit patient chart scenarios spanning multiple clinical encounters.
- Work with structured clinical data formats, including C-CDA XML and/or FHIR-formatted records.
- Develop gold-standard chronological summaries of complex patient medical histories.
- Synthesize diagnoses, procedures, medications, imaging, laboratory results, clinical findings, and treatment history across encounters.
- Identify duplicate or potentially redundant diagnostic imaging and testing, including repeat CT or MRI studies occurring within relevant time periods.
- Distinguish clinically meaningful repeat testing from appropriately repeated studies based on available documentation.
- Ensure each summary statement is traceable to a specific source chart note or clinical record.
- Develop evaluation rubrics assessing the completeness, factual accuracy, chronology, and source linkage of generated medical summaries.
- Evaluate whether summaries accurately represent the underlying patient record without introducing unsupported information.
- Participate in iterative evaluation, calibration, and quality-review activities.
- Follow project-specific clinical documentation, quality, confidentiality, and data-handling requirements.
Required Qualifications
Candidates should have:
- 3+ years of professional experience in Health Information Management (HIM), Clinical Documentation Improvement (CDI), or a closely related healthcare documentation discipline.
- Working knowledge of C-CDA XML and/or FHIR clinical data structures.
- Experience reviewing complex medical records across multiple encounters.
- Experience synthesizing longitudinal patient histories from multiple clinical documents.
- Ability to identify clinically redundant or duplicate diagnostic testing based on available medical-record evidence.
- Strong chronological summarization and structured-writing skills.
- Excellent attention to detail and source traceability.
- Ability to distinguish documented clinical facts from assumptions or unsupported conclusions.
- Ability to work independently on detailed clinical documentation tasks in a remote environment.
Preferred Qualifications
The following experience is preferred:
- RHIA, RHIT, CDIP, CCDS, or equivalent certification.
- Familiarity with HEDIS and/or MIPS quality measures.
- Experience with clinical data interoperability standards.
- Experience working with electronic health records (EHRs) or health information systems.
- Prior experience in medical-record abstraction or chart review.
- Experience with data annotation, clinical content evaluation, or AI/ML training-data projects.
- Experience developing clinical documentation guidelines, quality criteria, or evaluation rubrics.
Education / Expertise
Candidates with educational or professional backgrounds in one or more of the following areas are encouraged to apply:
- Health Information Management
- Clinical Documentation Improvement
- Health Information Technology
- Medical Record Administration
- Clinical Informatics
- Medical Coding
- Clinical Data Management
- Healthcare Quality
- Health Information Technology & Interoperability
- Equivalent professional experience may also be considered where appropriate.
Certifications
Relevant certifications may include:
- Registered Health Information Administrator (RHIA)
- Registered Health Information Technician (RHIT)
- Certified Documentation Improvement Practitioner (CDIP)
- Certified Clinical Documentation Specialist (CCDS)
- Other recognized HIM, CDI, or clinical documentation certifications
Job Details
- Type: Independent Contractor
- Markets: India | Philippines | United States
- Priority: Priority 1
- Start Date: Immediate joiners preferred
- Openings: Limited
- Schedule: Project-based; availability may vary based on workload and evaluation cycles
Important Notes
- Strong medical-record review and structured summarization experience is required.
- Contributors should be comfortable reviewing information across multiple patient encounters.
- Source traceability and factual accuracy are critical quality requirements.
- Contributors must avoid introducing information that is not supported by the underlying medical record.
- Work may involve complex longitudinal patient histories and structured clinical data.
- Contributors may participate in multiple evaluation, calibration, and quality-review rounds.
- Project access and task availability are subject to client requirements and business needs.
- All work must meet applicable confidentiality, quality, and project compliance requirements.
Work Arrangement
- Location: Remote
- Work Type: Independent Contractor
- Schedule: Project-based / Flexible, subject to project requirements
- Scope: India | Philippines | United States
Compensation
Actual earnings may vary based on task availability, productivity, quality performance, project requirements, certifications, domain expertise, and business needs.
How to Apply
Interested professionals may submit their application through the official application form.
Complete the application form
Please ensure your profile accurately reflects your HIM/CDI experience, certifications, medical-record review experience, and relevant technical expertise. Only shortlisted candidates will be contacted.
Equal Opportunity
Agents Only Technologies Inc. is committed to fostering an inclusive and diverse global community. We welcome talented individuals from a wide range of backgrounds, experiences, and perspectives. Opportunities are made available based on qualifications, skills, experience, and business needs, with the goal of building a collaborative environment where contributors can learn, grow, and succeed together.
