Clinical Documentation Specialist

Guidehouse

CDI Specialist managing comprehensive clinical chart reviews to enhance documentation quality and compliance. Collaborates with various healthcare professionals to assure regulatory standards are met.

Posted 7/29/2026full-timeRemote • 🇺🇸 United StatesMid-LevelSenior💰 $74,000 - $124,000 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in clinical documentation improvement, including comprehensive chart reviews and accurate DRG assignment, while ensuring compliance with coding guidelines and regulatory standards. Strong collaboration with healthcare teams to enhance documentation quality and patient care outcomes is essential.

Highest-signal resume keywords

Clinical Documentation Improvement (CDI)DRG AssignmentEncoder FamiliarityRegulatory Standards KnowledgePatient Care Experience

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Chart ReviewDocumentation ClarificationCoding Guidelines KnowledgeInitial Code AssignmentPhysician Query Initiation

Soft Skills

CollaborationCommunicationProblem-Solving

Tools & Technologies

CDI Software

Certifications & Qualifications

RNMDMD Equivalent (MBBS)

Industry Keywords

Inpatient CareCritical CareEmergency Department (ED)Medical-Surgical ExperienceCoding Clinics

About the role

Key responsibilities & impact

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.
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.

Requirements

What you’ll need

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

Benefits

Comp & perks

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