Clinical Documentation Specialist

Guidehouse; Cedar Lake (IN); Remote; USD 61,000 - 101,000; Full time

Benefits offered by this job

Medical insurance

401(k) Retirement Plan

Parental Leave

Life insurance

Tuition reimbursement

Employee referral program

Job summary

Guidehouse is hiring a Clinical Documentation Specialist to perform inpatient chart reviews and ensure documentation supports accurate coding and CMS compliance. Remote position in the US.

The role requires 2–4 years CDI experience, 4+ years direct patient care, and encoder/CDI software familiarity. Collaboration with coders, educators, managers, and providers is essential to improve documentation quality.

Qualifications

• Minimum 2–4 years of relevant CDI/coding experience.
• 4+ years direct patient care in inpatient settings or strong med-surg/critical care background.
• 2+ years CDI experience.
• Familiarity with encoder and DRG assignment; knowledge of coding guidelines.

Responsibilities

• Conduct concurrent chart reviews to ensure documentation supports accurate coding.
• Perform initial code assignment for DRG and data entry in CDI software.
• Update working DRG as documentation supports and communicate changes to CDI team.
• Initiate compliant physician queries and follow up with physicians for responses.

Skills

Critical thinking

Analytical skills

Interpersonal skills

Communication with physicians

Education

RN/MD/MD Equivalent

CCS/CDIP certification

Tools

Encoder

CDI software systems

Job description

Clinical Documentation Specialist page is loaded## Clinical Documentation Specialistlocations: US - Remote (Any location)time type: Full timeposted on: Posted Todayjob requisition id: 46303**Job Family:**CDI Specialist**Travel Required:**None**Clearance Required:**None**What You Will Do:*** 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:*** Requires a University Degree and minimum 2-4 years of prior relevant experience; some roles may require graduate-level education Master's or Doctorate degree (Relevant experience may be substituted for formal education or advanced degree)* 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, critical care, ED or strong med-surg experience or substituted with prior 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#Indeedsponsered#LI-DNIThe annual salary range for this position is $61,000.00-$101,000.00. Compensation decisions depend on a wide range of factors, including but not limited to skill sets, experience and training, security clearances, licensure and certifications, and other business and organizational needs.**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* 401(k) Retirement Plan* Basic Life & Supplemental Life* Health Savings Account, Dental/Vision & Dependent Care Flexible Spending Accounts* Short-Term & Long-Term Disability* Tuition Reimbursement, Personal Development & Learning Opportunities* Skills Development & Certifications* Employee Referral Program* Corporate Sponsored Events & Community Outreach* Emergency Back-Up Childcare Program**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.If you have visited our website for information about employment opportunities, or to apply for a position, and you require an accommodation, please contact Guidehouse Recruiting at 1-571-633-1711 or via email at [e-mail]. All information you provide will be kept confidential and will be used only to the extent required to provide needed reasonable accommodation.All communication regarding recruitment for a Guidehouse position will be sent from Guidehouse email domains including @guidehouse.com or [e-mail]. Correspondence received by an applicant from any other domain should be considered unauthorized and will not be honored by Guidehouse. Note that Guidehouse will never charge a fee or require a money transfer at any stage of the recruitment process and does not collect fees from educational institutions for participation in a recruitment event. Never provide your banking information to a third party purporting to need that information to proceed in the hiring process.If any person or organization demands money related to a job opportunity with Guidehouse, please report the matter to Guidehouse's Ethics Hotline. If you want to check the validity of correspondence you have received, please contact [e-mail]. Guidehouse is not responsible for losses incurred (monetary or otherwise) from an applicant's dealings with unauthorized third parties.*Guidehouse does not accept unsolicited resumes through or from search firms or staffing agencies. All unsolicited resumes will be considered the property of Guidehouse and Guidehouse will not be obligated to pay a placement fee.*