Clinical Documentation Improvement Specialist

Guidehouse; United States; Remote; USD 74,000 - 124,000; Full time

Benefits offered by this job

Medical, Rx, Dental & Vision Insurance

Paid Holidays

Tuition Reimbursement

401(k) Retirement Plan

Life Insurance

Disability Insurance

Employee Referral Program

Wellness Programs

Job summary

Guidehouse is seeking a CDI Specialist to perform comprehensive secondary clinical chart reviews and ensure documentation reflects severity of illness and regulatory standards. You will collaborate with Coders, Educators, Quality, Case Managers and Providers to support accurate coding.

Daily, you will review inpatient records, assign initial DRG codes, and enter data in CDI software. You will update working DRGs as needed and raise physician queries when documentation is unclear, coordinating

Qualifications

• Bachelor’s degree required; RN/MD or MD Equivalent preferred.
• 4+ years direct patient care in inpatient settings; 2+ years CDI experience.
• Familiarity with encoder and DRG assignment; knowledge of coding guidelines.

Responsibilities

• Perform comprehensive secondary clinical chart reviews to identify missed opportunities for documentation clarification.
• Collaborate with Coders, Coding Educators, Coding Quality Auditors, Case Managers, Quality Dept and Providers to ensure documentation is clinically appropriate and reflects CMS/regulatory standards.
• Conduct daily inpatient record reviews to ensure complete and accurate physician documentation at discharge for proper coding.

Skills

Critical thinking

Interpersonal skills

Communication skills

Medical terminology knowledge

Education

Bachelor’s degree

RN/MD/MD Equivalent

Tools

EHR systems

CDI software

Encoders

Job description

Guidehouse is seeking a CDI Specialist to perform comprehensive secondary clinical chart reviews and ensure documentation reflects severity of illness and regulatory standards. You will collaborate with Coders, Educators, Quality, Case Managers and Providers to support accurate coding.

Daily, you will review inpatient records, assign initial DRG codes, and enter data in CDI software. You will update working DRGs as needed and raise physician queries when documentation is unclear, coordinating