Remote CDI Specialist — Clinical Documentation Improvement

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

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.