Clinical Documentation Specialist

Guidehouse • Greenville, SC

3d • $61,000 - $101,000

About The Position

The Clinical Documentation Specialist (CDI Specialist) conducts comprehensive secondary clinical chart reviews to identify potential missed opportunities for documentation clarification. The role collaborates with Coders, Coding Educators, Coding Quality Auditors, Case Managers, the Quality Department, and providers to ensure documentation is clinically appropriate, accurately reflects patient severity of illness and risk of mortality, and aligns with current CMS and other regulatory standards.

The specialist performs daily concurrent reviews of inpatient records on assigned units to ensure complete and accurate physician and/or clinician documentation is present at discharge for accurate, timely, and compliant coding. The role reviews admissions, makes initial code assignments for working DRGs, records review information in CDI software or on a worksheet, updates working DRGs as documentation or query responses support changes, and initiates compliant physician queries when documentation is confusing, ambiguous, or missing.

Requirements

• University degree and a minimum of 2–4 years of prior relevant experience; relevant experience may substitute for formal education or an advanced degree. Some roles may require a master's or doctorate.
• One of the following credentials: RN, MD, MD equivalent (MBBS), or CCS.
• At least 4 years of experience providing direct patient care to acute and chronically ill patients in inpatient settings, critical care, the ED, or with strong med-surg experience; this may be substituted with prior experience.
• At least 2 years of prior CDI experience.
• Familiarity with encoders and DRG assignment.
• Maintain current working knowledge of official coding guidelines and coding clinics.

Nice To Haves

• CCDS or CDIP certification preferred.
• ED/critical care, case management, or inpatient acute care (referral hospital) experience.
• Strong critical-thinking skills, interpersonal skills, and clinical knowledge base.
• Coding, Case Management, and/or Utilization Review experience preferred.
• Strong clinical understanding of disease processes.
• Demonstrated critical thinking and 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, including proficiency with EHR systems, CDI software systems, and encoders.

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, the Quality Department, and providers to support clinically appropriate, accurate, and compliant documentation.
• Conduct daily concurrent reviews of inpatient records on assigned units to ensure complete and accurate documentation at discharge.
• Review daily admissions to assigned units and perform initial code assignments for working DRGs.
• Complete CDI software data entry for initial and follow-up case reviews, or prepare a worksheet that includes code and DRG assignments, and submit it to the Program Assistant.
• Update working DRGs when documentation or physician query responses support a change in DRG assignment.
• Notify the CDI Coordinator when daily review assignment volume is too high or low so assignments can be adjusted among the team.
• Initiate compliant physician queries when documentation is confusing, ambiguous, or missing, and follow up with physicians to seek timely responses.
• Use the cited AHIMA practice briefs as guidance for the query process.

Benefits

• Medical, prescription, dental, and vision insurance.
• Personal and family sick time and company-paid holidays.
• Position may be eligible for a discretionary variable incentive bonus.
• Parental leave.
• 401(k) retirement plan.
• Basic and supplemental life insurance.
• Health Savings Account and dental/vision and dependent care Flexible Spending Accounts.
• Short-term and long-term disability.
• Tuition reimbursement, personal development, and learning opportunities.
• Skills development and certifications.
• Employee referral program.
• Corporate-sponsored events and community outreach.
• Emergency back-up childcare program.
• Flexible benefits package.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level