Clinical Documentation Specialist

🔥 0 minutes ago

🇺🇸 United States – Remote

💵 $74k - $124k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🏥📝 Medical Writer

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Guidehouse

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 2018

🏥 Healthcare

🎖️ Defense

📦 Logistics

💰 Grant on 2023-02

Healthcare • Defense • Logistics

Guidehouse is a global consultancy offering advisory, digital, and managed services across commercial and public sectors. It is purpose-built to support industries such as national security, financial services, healthcare, energy, and infrastructure. Guidehouse collaborates with leaders to navigate complexity and drives transformational changes that impact the future. Their expertise spans data analytics, digital technologies, risk management, and more, with a strong emphasis on sustainability and innovation.

📋 Description

• Conduct comprehensive secondary clinical chart reviews to identify potential missed opportunities for documentation clarification • Collaborate with Coders, Coding Educators, Coding Quality Auditors, Case managers, Quality Department and Providers • Conduct daily, concurrent review of inpatient records on assigned units • Ensure complete and accurate physician and clinician documentation is present at discharge for accurate, timely, and compliant coding • Review daily admissions and perform initial code assignment for a working DRG • Complete CDI software data entry for initial and follow-up case reviews or worksheets, including code and DRG assignment, and submit to Program Assistant • Update the working DRG when documentation or physician query responses support a change • Communicate with the CDI Coordinator when daily review volume requires assignment adjustments • Initiate compliant physician queries when documentation is confusing, ambiguous, or missing • Follow up with physicians to obtain timely query responses using AHIMA practice briefs as guidance

🎯 Requirements

• 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 • CCDS, CDIP preferred • ED/Critical care or case management; or inpatient acute care (referral hospital) preferred • Strong critical thinking skills • Strong interpersonal skills • Strong clinical knowledge base • Coding, Case Management and/or Utilization Review experience 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

🏖️ 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 • Flexible benefits package