Clinical Documentation

3 weeks ago

AUSTIN, United States Guidehouse Full time

Job Family:

CDI Specialist


Travel Required:

Up to 10%


Clearance Required:

None

What You Will Do:

The Clinical Documentation Improvement (CDI) Specialist manages comprehensive secondary clinical chart reviews to find potential missed opportunities for documentation clarification. Collaborates 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. This position is 100% remote.

  • 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:

  • At least one of the following: RN, MD, or MD Equivalent
  • At least 2-4 years acute care inpatient hospital coding or CDI experience

What Would Be Nice to Have:

  • CCDS, CDIP preferred.
  • Strong clinical understanding of disease process.
  • Familiarity with encoder and DRG assignment
  • Demonstrates critical thinking, analytical skills, and ability to resolve problems.
  • Maintains current working knowledge of Official Coding Guidelines and Coding Clinics
  • Strong knowledge of medical terminology, anatomy, physiology, microbiology, and disease processes
  • Excellent communication skills, employing tact and effectiveness.
  • 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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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 Employment Opportunity / Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, national origin, ancestry, citizenship status, military status, protected veteran status, religion, creed, physical or mental disability, medical condition, marital status, sex, sexual orientation, gender, gender identity or expression, age, genetic information, 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 at RecruitingAccommodation@guidehouse.com. All information you provide will be kept confidential and will be used only to the extent required to provide needed reasonable accommodation.


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.

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