Remote CDI Specialist: Elevate Chart Accuracy

Dovel Technologies, Inc; United States; Remote; USD 61,000 - 101,000; Full time

Benefits offered by this job

Medical, Rx, Dental & Vision Insurance

Parental Leave and Adoption Assistance

401(k) Retirement Plan

Tuition Reimbursement

Job summary

Guidehouse is seeking a Clinical Documentation Specialist to perform comprehensive chart reviews and ensure accurate coding reflecting the severity of illness and risk of mortality. The role requires collaboration with coders, clinicians, and quality teams to maintain CMS compliance and high documentation quality.

The ideal candidate has a Bachelor's degree with 4+ years of direct inpatient care and 2+ years CDI experience, plus familiarity with encoder/DRG assignments.

Qualifications

• Bachelor's degree is required.
• 4+ years direct patient care in inpatient settings.
• 2+ years CDI experience.
• Familiarity with encoder and DRG assignment.
• Maintain knowledge of official coding guidelines and coding clinics.

Responsibilities

• Perform comprehensive secondary clinical chart reviews to identify missed documentation opportunities.
• Collaborate with coders, educators, auditors, case managers, quality dept. and providers to ensure documentation reflects severity and CMS standards.
• Conduct daily concurrent reviews of inpatient records on assigned units for accurate coding at discharge.
• Enter initial DRG and complete CDI data entry for reviews; update working DRG as supported by documentation.
• Initiate compliant physician queries when documentation is unclear and follow up with physicians.

Skills

Critical thinking

Interpersonal skills

Clinical knowledge

Communication with physicians

Education

Bachelor's degree

CCDS

CDIP

RN or MD or MD Equivalent

Tools

EHR systems

CDI software

Encoders

Job description

Guidehouse is seeking a Clinical Documentation Specialist to perform comprehensive chart reviews and ensure accurate coding reflecting the severity of illness and risk of mortality. The role requires collaboration with coders, clinicians, and quality teams to maintain CMS compliance and high documentation quality.

The ideal candidate has a Bachelor's degree with 4+ years of direct inpatient care and 2+ years CDI experience, plus familiarity with encoder/DRG assignments.