Clinical Documentation Specialist

🕒 il y a 9 jours

🇺🇸 États-Unis – Télétravail

💵 $74 000 - $124 000 / an

⏰ Temps Plein

🟡 Intermédiaire

🟠 Senior

🏥📝 Rédacteur Médical

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Guidehouse

Site WebLinkedInTous les Emplois

10 000+ employés

Fondée en 2018

🏥 Santé

🎖️ Défense

📦 Logistique

💰 Grant en 2023-02

Healthcare • Defense • Logistics

Guidehouse est un cabinet de conseil international qui propose des services de conseil, digitaux et managés pour les secteurs privé et public. Conçu spécifiquement pour accompagner des industries telles que la sécurité nationale, les services financiers, la santé, l’énergie et les infrastructures, Guidehouse collabore avec des dirigeants pour naviguer dans la complexité et accélérer des transformations qui façonnent l’avenir. Son expertise couvre notamment le data analytics, les technologies digitales, le risk management, et bien plus encore, avec un fort accent sur le développement durable et l’innovation.

Description

• The CDI Specialist is responsible for comprehensive secondary clinical chart reviews to identify 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. • 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.

🎯 Exigences

• Bachelor's degree • One of the following: RN, MD, or MD Equivalent (MBBS) • 4+ years' experience providing direct patient care to acute and chronically ill patients in inpatient settings, critical care, ED or strong med-surg experience • 2 + years prior CDI experience • Familiarity with encoder and DRG assignment • Maintain current working knowledge of official coding guidelines and coding clinics

🏖️ Avantages

• 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