Clinical Documentation (CDI) Specialist - Hybrid ( Austin / TX)

Job Family : CDI Specialist

CDI Specialist

Travel Required : Up to 10%

Up to 10%

Clearance Required : None

None

What You Will Do :

The CDI Specialist is responsible for comprehensive secondary clinical chart reviews to identify potential missed opportunities for documentation clarification.

Collaborates 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.

This position will require two days working onsite at a major hospital facility in Austin, Texas and three days working remotely.

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 :

At least one of the following : RN, MD or MD Equivalent or RHIA, RHIT or CCS and university degree (Relevant experience may be substituted for formal education or advanced degree)

At least 2 years acute care inpatient hospital coding or CDI experience

Familiarity with encoder and DRG assignment

Demonstrate critical thinking, analytical skills and ability to resolve problems.

Maintain current working knowledge of Official Coding Guidelines and Coding Clinics

Strong knowledge of medical terminology, anatomy, physiology, microbiology and disease processes

Excellent communication skills, employing tact and effectiveness.

Ability to converse with physicians in sometimes difficult scenarios.

Strong typing and computer skills; proficiency with HER systems, CDI software systems and encoders

What Would Be Nice To Have :

CCDS, CDIP preferred, but not required.

Medical Coders- previous inpatient medical record review experience

Strong clinical understanding of disease process.

LI-Remote

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