Clinical Documentation Improvement (CDI) Specialist - Onsite

Overview CDI Specialist responsible for comprehensive secondary clinical chart reviews to identify potential missed opportunities for documentation clarification. Collaborates with Coders, Coding Educators, Coding Quality Auditors, Case Managers, Quality Department, and Providers to ensure documentation is clinically appropriate, accurately reflects the severity of illness and risk of mortality, and is compliant with CMS or other regulatory standards. Responsibilities Conduct 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. Review daily admissions to the assigned unit, perform initial code assignment for a working DRG and complete CDI software data entry for initial and follow-up case reviews (or worksheet including code and DRG assignment) and submit to Program Assistant. Update the “working DRG” as documentation supports, or as physician query answers support a change in the DRG assignment. Communicate to the CDI Coordinator when the volume of daily review assignments is too high or too low so that the CDI Coordinator can assist in adjusting review assignments among the team. Initiate compliant physician queries when documentation is confusing, ambiguous, or missing and follow up with the physician to seek immediate response to the query, following the guidance of AHIMA practice briefs as applicable. 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 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 #J-18808-Ljbffr Guidehouse