Guidehouse
ClinicalDocumentationImprovement(CDI)Specialist-Onsite
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“Clinical Documentation Improvement (CDI) Specialist - Onsite at Guidehouse. Skills: clinical chart reviews, documentation clarification, physician query, DRG assignment. Conducts 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.. Reviews daily admissions to assigned unit, perform initial code assignment for a working DRG and comp”
What You'll Achieve.
assure documentation is clinically appropriate, accurately reflects the severity of illness and risk of mortality for the patient and is reflective of current CMS or other regulatory standards.
Industry & Context.
critical thinking; analytical skills; ability to resolve problems
Travel Required: None, Clearance Required: None
What They're Looking For.
Must Have
Bachelor's degree, 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
Nice to Have
CCDS, CDIP preferred, clinical understanding of disease process, Demonstrate critical thinking, analytical skills, and ability to resolve problems., knowledge of medical terminology, anatomy, physiology, microbiology, and disease processes, Ability to converse with physicians in sometimes difficult scenarios, typing and computer proficiency with EHR systems, CDI software systems and encoders
What You'll Do.
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
and compliant coding.
Reviews daily admissions to assigned unit
perform initial code assignment for a working DRG and complete CDI software data entry for initial and follows up case reviews (or worksheet to include code and DRG assignment) and submit to Program Assistant.
Updates “working DRG” as documentation supports
or physician query answer supports a change in the DRG assignment.
Initiates compliant physician queries when documentation is confusing
or missing and follows up with MD to seek immediate response to query
How You'll Work.
Team & Collaboration
collaborate closely with Coders, Coding Educators, Coding Quality Auditors, Case managers, Quality Department and Providers; Communicates to the CDI Coordinator when volume of daily review assignments is too high or low so that CDI Coordinator can assist in adjusting review assignments amongst the team.
Communication Scope
Ability to converse with physicians in sometimes difficult scenarios
Full Job Description
**_Job Family_ :** CDI Specialist ** _Travel Required_ :** None ** _Clearance Required_ :** None ** _What You Will Do_ :** The CDI Specialist is responsible for comprehensive secondary clinical chart reviews to identify potential missed opportunities for documentation clarification. In this role, you will collaborate closely with Coders, Coding Educators, Coding Quality Auditors, Case managers, Quality Department and Providers to assure documentation is clinically appropriate, accurately reflects the severity of illness and risk of mortality for the patient and is reflective of current CMS or other regulatory standards. * Conducts 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. * Reviews daily admissions to assigned unit, perform initial code assignment for a working DRG and complete CDI software data entry for initial and follows up case reviews (or worksheet to include code and DRG assignment) and submit to Program Assistant. * Updates “working DRG” as documentation supports, or physician query answer supports a change in the DRG assignment. * Communicates to the CDI Coordinator when volume of daily review assignments is too high or low so that CDI Coordinator can assist in adjusting review assignments amongst the team. * Initiates compliant physician queries when documentation is confusing, ambiguous, or missing and follows up with MD to seek immediate response to query (utilizing the following AHIMA practice briefs as a guide: “ _Managing an Effective Query Process_ ,” October 2008 _and “Guidance for Clinical Documentation Improvement Programs”_ , May 2010). **_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 worki
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