Clinical Documentation Specialist
Guidehouse · US - Remote (Any location) ·
- Work mode
- Remote
- Category
- Technical writing
- Experience
- 4+ years
Job Family:
CDI Specialist
Travel Required:
Clearance Required:
The CDI Specialist is responsible for comprehensive secondary clinical chart reviews to identify potential missed opportunities for documentation clarification. Collaborates closely with Coders, Coding Educators, Coding Quality Auditors, Case managers, Quality Department and Providers to assure documentation is clinically appropriate, accurately reflects the severity of illness and risk of mortality for the patient and is reflective of current CMS or other regulatory standards.
Conducts daily, concurrent review of inpatient records on assigned unit(s) to ensure complete and accurate physician and or clinician documentation is present at the time of discharge for accurate, timely, and compliant coding.
Reviews daily admissions to assigned unit, perform initial code assignment for a working DRG and complete CDI software data entry for initial and follows up case reviews (or worksheet to include code and DRG assignment) and submit to Program Assistant.
Updates “working DRG” as documentation supports, or physician query answer supports a change in the DRG assignment.
Communicates to the CDI Coordinator when volume of daily review assignments is too high or low so that CDI Coordinator can assist in adjusting review assignments amongst the team.
Initiates compliant physician queries when documentation is confusing, ambiguous, or missing and follows up with MD to seek immediate response to query (utilizing the following AHIMA practice briefs as a guide: “Managing an Effective Query Process,” October 2008 and “Guidance for Clinical Documentation Improvement Programs”, May 2010).
What You Will Need:
Bachelor's degree
One of the following: RN, MD, or MD Equivalent (MBBS)
4+ years' experience providing direct patient care to acute and chronically ill patients in inpatient settings, critical care, ED or strong med-surg experience
2 + years prior CDI experience
Familiarity with encoder and DRG assignment
Maintain current working knowledge of official coding guidelines and coding clinics
What Would Be Nice to Have:
CCDS, CDIP preferred
ED/Critical care or case management; or inpatient acute care (referral hospital); strong critical thinking skills; strong interpersonal skills; strong clinical knowledge base.
Coding, Case Management and/or Utilization Review experience preferred.
Strong clinical understanding of disease process
Demonstrate critical thinking, analytical skills, and ability to resolve problems.
Strong knowledge of medical terminology, anatomy, physiology, microbiology, and disease processes
Ability to converse with physicians in sometimes difficult scenarios
Strong typing and computer skills; proficiency with EHR systems, CDI software systems and encoders
What We Offer:
Guidehouse offers a comprehensive, total rewards package that includes competitive compensation and a flexible benefits package that reflects our commitment to creating a diverse and supportive workplace.
Benefits include:
Medical, Rx, Dental & Vision Insurance
Personal and Family Sick Time & Company Paid Holidays
Position may be eligible for a discretionary variable incentive bonus
Parental Leave and Adoption Assistance
401(k) Retirement Plan
Basic Life & Supplemental Life
Health Savings Account, Dental/Vision & Dependent Care Flexible Spending Accounts
Short-Term & Long-Term Disability
Student Loan PayDown
Tuition Reimbursement, Personal Development & Learning Opportunities
Skills Development & Certifications
Employee Referral Program
Corporate Sponsored Events & Community Outreach
Emergency Back-Up Childcare Program
Mobility Stipend
About Guidehouse
Guidehouse is an Equal Opportunity Employer–Protected Veterans, Individuals with Disabilities or any other basis protected by law, ordinance, or regulation.
Guidehouse will consider for employment qualified applicants with criminal histories in a manner consistent with the requirements of applicable law or ordinance including the Fair Chance Ordinance of Los Angeles and San Francisco.
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