The Clinical Documentation Improvement (CDI) Specialist conducts thorough reviews of inpatient clinical records to ensure accurate, compliant, and complete documentation that reflects patient severity and supports correct coding. This role involves collaboration with healthcare providers and coding professionals to clarify and improve clinical documentation, facilitating appropriate DRG assignment and regulatory compliance. The specialist also initiates physician queries when documentation is unclear and maintains up-to-date knowledge of coding guidelines and healthcare regulations.
Job Family:
CDI Specialist
Travel Required:
Clearance Required:
What You Will Do:
The CDI Specialist is responsible for comprehensive secondary clinical chart reviews to identify potential missed opportunities for documentation clarification. In this role, you will collaborate 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 degree
One of the following: RN, MD, or MD Equivalent (MBBS)
2-4 years acute care inpatient hospital coding or CDI experience
Familiarity with encoder and DRG assignment
Maintain current working knowledge of official coding guidelines and coding clinics
What Would Be Nice to Have:
CCDS, CDIP preferred
Strong clinical understanding of disease process
Demonstrate critical thinking, analytical skills, and ability to resolve problems.
Strong knowledge of medical terminology, anatomy, physiology, microbiology, and disease processes
Ability to converse with physicians in sometimes difficult scenarios
Strong typing and computer skills; proficiency with EHR systems, CDI software systems and encoders
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The 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 Insurance
Personal and Family Sick Time & Company Paid Holidays
Position may be eligible for a discretionary variable incentive bonus
Parental Leave
401(k) Retirement Plan
Basic Life & Supplemental Life
Health Savings Account, Dental/Vision & Dependent Care Flexible Spending Accounts
Short-Term & Long-Term Disability
Tuition Reimbursement, Personal Development & Learning Opportunities
Skills Development & Certifications
Employee Referral Program
Corporate Sponsored Events & Community Outreach
Emergency Back-Up Childcare Program
About Guidehouse
Guidehouse 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 atRecruitingAccommodation@guidehouse.com. 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 orguidehouse@myworkday.com. 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 contactrecruiting@guidehouse.com. 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.
clinical documentation improvement, medical coding, DRG assignment, health information management, physician queries, acute care coding, clinical chart review, regulatory compliance, EHR systems, CDI software
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