Clinical Documentation Specialist: Elevate Coding

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

Benefits offered by this job

Medical, Rx, Dental & Vision Insurance

401(k) Retirement Plan

Paid Holidays

Tuition Reimbursement

Job summary

Guidehouse is seeking a CDI Specialist to perform comprehensive secondary clinical chart reviews ensuring documentation reflects severity of illness and aligns with CMS standards. You will collaborate with coders, educators, auditors, case managers and providers to maintain high-quality documentation.

You will conduct daily inpatient reviews, assign initial DRG, and manage CDI software data entry. Queries will be initiated when documentation is unclear and followed up with physicians.

Qualifications

• Bachelor's degree required.
• RN, MD, or MD equivalent required.
• 4+ years direct patient care in inpatient settings.
• 2+ years CDI experience.
• Familiarity with encoder and DRG assignment.
• Knowledge of official coding guidelines and coding clinics.

Responsibilities

• Perform comprehensive secondary clinical chart reviews to identify missed documentation opportunities.
• Collaborate with Coders, Coding Educators, Auditers, Case managers and Providers to ensure clinically appropriate documentation reflecting severity of illness and risk of mortality.
• Conduct daily inpatient record reviews to ensure complete and accurate documentation at discharge.
• Update working DRG as supported by documentation or queries and enter data into the CDI system.
• Initiate compliant physician queries when documentation is unclear or missing and follow up with physicians.

Skills

Critical thinking

Interpersonal skills

CDI experience

Query processes

Education

Bachelor's degree

RN/MD/MD Equivalent

Tools

Encoder

CDI software

EHR systems

Job description

Guidehouse is seeking a CDI Specialist to perform comprehensive secondary clinical chart reviews ensuring documentation reflects severity of illness and aligns with CMS standards. You will collaborate with coders, educators, auditors, case managers and providers to maintain high-quality documentation.

You will conduct daily inpatient reviews, assign initial DRG, and manage CDI software data entry. Queries will be initiated when documentation is unclear and followed up with physicians.