CDI & Clinical Documentation Specialist

Guidehouse; Oregon; Híbrido; USD 61.000 - 101.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Medical Insurance

Sick Time & Holidays

Bonus Eligible

Parental Leave

401(k)

Descripción de la vacante

Guidehouse is seeking a CDI Specialist to perform comprehensive chart reviews and collaborate with coders, educators and case managers to ensure accurate documentation. The role focuses on capturing severity of illness, risk of mortality, and regulatory alignment during inpatient care.

Daily concurrent reviews on assigned units will support timely discharge documentation, with working DRG updates and physician queries as needed. Strong knowledge of coding guidelines is essential.

Formación

• Requires a University Degree and 2-4 years of prior relevant experience; some roles may require graduate-level education
• One of the following: RN, MD, or MD Equivalent (MBBS), CCS
• 4+ years' experience providing direct patient care to acute and chronically ill patients in inpatient settings
• 2 + years prior CDI experience
• Familiarity with encoder and DRG assignment
• Maintain current working knowledge of official coding guidelines and coding clinics

Responsabilidades

• The CDI Specialist performs comprehensive secondary clinical chart reviews to identify missed opportunities for documentation clarification.
• Collaborates with Coders, Coding Educators, Coding Quality Auditors, Case managers, Quality Department and Providers to ensure documentation reflects severity of illness and regulatory standards.
• Conducts daily, concurrent review of inpatient records to ensure complete and accurate documentation at discharge.
• Reviews daily admissions to assign a working DRG and completes CDI software data entry.
• Updates working DRG as documentation/queries support changes.
• Initiates compliant physician queries when documentation is unclear or missing and follows up with physicians.

Conocimientos

CDI

Clinical documentation

Inpatient coding

Physician communication

EHR systems

Educación

University Degree

Master's or Doctorate degree

Herramientas

Encoder familiarity

DRG assignment

CDI software systems

Encoders

Descripción del empleo

Guidehouse is seeking a CDI Specialist to perform comprehensive chart reviews and collaborate with coders, educators and case managers to ensure accurate documentation. The role focuses on capturing severity of illness, risk of mortality, and regulatory alignment during inpatient care.

Daily concurrent reviews on assigned units will support timely discharge documentation, with working DRG updates and physician queries as needed. Strong knowledge of coding guidelines is essential.