Clinical Documentation Improvement (CDI) Specialist - Onsite

CDI Specialist

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.

Responsibilities:

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).

Requirements:

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

Preferred Qualifications:

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

Salary Range: $74,000.00-$124,000.00

Benefits:

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

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.