Clinical Documentation Specialist
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Job Description
Clinical Documentation Specialist reviewing inpatient charts for accurate documentation and DRG coding. Supporting Guidehouse’s healthcare services through compliant physician queries and clinical documentation improvement.
Responsibilities:
- 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
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