Senior Clinical Documentation & Coding 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

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.