Clinical Documentation Specialist

Guidehouse; Washington (District of Columbia); On-site; USD 74,000 - 124,000; Full time

Benefits offered by this job

Medical, Rx, Dental & Vision Insurance

401(k) Retirement Plan

Parental Leave

Tuition Reimbursement

Job summary

Guidehouse seeks a CDI Specialist to perform comprehensive chart reviews on inpatient records, ensuring documentation reflects illness severity and regulatory standards. You will collaborate with Coders, Educators, Case managers and Providers to support accurate DRG assignments and timely coding at discharge.

The role requires a Bachelor's degree, 4+ years clinical care, and 2+ years CDI experience. Strong communication with physicians and knowledge of coding guidelines are essential.

Qualifications

• Bachelor's degree required.
• RN, MD, or MD Equivalent preferred.
• 4+ years direct patient care in inpatient settings.
• 2+ years CDI experience.

Responsibilities

• Conduct comprehensive secondary clinical chart reviews to identify missed documentation opportunities.
• Collaborate with Coders, Educators, Auditors, Case managers, Quality Dept. and Providers to ensure CMS/regulatory alignment.
• Perform initial code assignment and CDI data entry for DRG, updating as needed.
• Initiate compliant physician queries when documentation is unclear or missing.

Skills

Critical thinking

Analytical skills

Interpersonal skills

Clinical knowledge

Communication with physicians

Education

Bachelor's degree

Tools

Encoder

DRG assignment

CDI software

EHR systems

Job description

Job Family:CDI SpecialistTravel Required:NoneClearance Required:NoneWhat 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:Bachelor's degreeOne 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 experience2 + years prior CDI experienceFamiliarity with encoder and DRG assignmentMaintain current working knowledge of official coding guidelines and coding clinicsWhat Would Be Nice to Have:CCDS, CDIP preferredED/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 processDemonstrate critical thinking, analytical skills, and ability to resolve problems.Strong knowledge of medical terminology, anatomy, physiology, microbiology, and disease processesAbility to converse with physicians in sometimes difficult scenariosStrong typing and computer skills; proficiency with EHR systems, CDI software systems and encoders#Indeedsponsored#LI-DNIThe annual salary range for this position is $74,000.00-$124,000.00. 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 InsurancePersonal and Family Sick Time & Company Paid HolidaysPosition may be eligible for a discretionary variable incentive bonusParental Leave401(k) Retirement PlanBasic Life & Supplemental LifeHealth Savings Account, Dental/Vision & Dependent Care Flexible Spending AccountsShort-Term & Long-Term DisabilityTuition Reimbursement, Personal Development & Learning OpportunitiesSkills Development & CertificationsEmployee Referral ProgramCorporate Sponsored Events & Community OutreachEmergency Back-Up Childcare ProgramAbout GuidehouseGuidehouse 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.