Clinical Documentation Specialist

Guidehouse • Greenville, SC

2d

About The Position

The Clinical Documentation Specialist (CDI Specialist) conducts comprehensive secondary clinical chart reviews to identify 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 meets current CMS or other regulatory standards.

The specialist reviews inpatient records daily and concurrently on assigned units to help ensure complete and accurate physician or clinician documentation is present at discharge for accurate, timely, and compliant coding. Responsibilities include reviewing admissions, making initial code and working DRG assignments, entering review information into CDI software or a worksheet, updating working DRGs when documentation or query responses support a change, and submitting work to the Program Assistant. The specialist also communicates review-volume concerns to the CDI Coordinator and initiates compliant physician queries when documentation is confusing, ambiguous, or missing, following up with physicians to seek timely responses.

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.
• One of the following credentials: RN, MD or MD equivalent (MBBS), or CCS.
• Four or more years of experience providing direct patient care to acutely and chronically ill patients in inpatient settings, critical care, the ED, or with strong med-surg experience; prior experience may be substituted.
• Two or more 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 credential.
• ED, critical care, case management, or inpatient acute-care (referral hospital) experience.
• Strong critical-thinking and interpersonal skills, and a strong clinical knowledge base.
• Coding, Case Management, and/or Utilization Review experience.
• Strong clinical understanding of disease processes.
• Ability to demonstrate critical thinking and analytical skills and 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 and accurate documentation.
• Conduct daily, concurrent reviews of inpatient records on assigned units to ensure complete and accurate documentation at discharge for timely, compliant coding.
• Review daily admissions to assigned units and perform initial code assignment for a working DRG.
• Complete CDI software data entry for initial and follow-up case reviews, or complete a worksheet that includes code and DRG assignment, and submit it to the Program Assistant.
• Update working DRGs when documentation or a physician query response supports a change in DRG assignment.
• Notify the CDI Coordinator when the volume of daily review assignments is too high or too low so assignments can be adjusted.
• Initiate compliant physician queries when documentation is confusing, ambiguous, or missing, and follow up with physicians to seek an immediate response.

Benefits

• Medical, prescription, dental, and 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 and supplemental life insurance
• Health Savings Account
• 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

What This Job Offers

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