Clinical Documentation Specialist

Guidehouse

. Conduct comprehensive secondary clinical chart reviews to identify potential missed opportunities for documentation clarification .

Posted 11/3/2026full-timeRemote • United StatesMid-LevelSenior💰 $61,000 - $101,000 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in Clinical Documentation Improvement (CDI) with a strong understanding of coding guidelines, DRG assignment, and medical terminology. Proficient in collaborating with healthcare professionals to ensure accurate documentation and coding compliance.

Highest-signal resume keywords

Clinical Documentation Improvement (CDI)DRG AssignmentCoding Guidelines KnowledgeEncoder FamiliarityStrong Clinical Knowledge Base

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical Chart ReviewCode AssignmentData Entry for CDI SoftwareDocumentation ClarificationMedical TerminologyAnatomy KnowledgePhysiology KnowledgeMicrobiology KnowledgeCritical ThinkingAnalytical Skills

Soft Skills

Interpersonal SkillsProblem-Solving AbilityCommunication Skills

Tools & Technologies

EHR SystemsCDI Software SystemsEncoders

Certifications & Qualifications

RNMDMD Equivalent (MBBS)CCSCCDSCDIP

Industry Keywords

Inpatient CareAcute CareCritical CareCase ManagementUtilization ReviewDocumentation CompliancePhysician QueriesHealthcare CollaborationCoding Quality AuditsPatient Care Experience

About the role

Key responsibilities & impact

Conduct comprehensive secondary clinical chart reviews to identify potential missed opportunities for documentation clarification
Collaborate with Coders, Coding Educators, Coding Quality Auditors, Case Managers, Quality Department and Providers
Conduct daily, concurrent review of inpatient records on assigned units
Ensure complete and accurate physician and clinician documentation is present at discharge for accurate, timely and compliant coding
Review daily admissions and perform initial code assignment for a working DRG
Complete CDI software data entry for initial and follow-up case reviews or worksheets including code and DRG assignment
Update the working DRG when documentation or physician query responses support a change
Communicate with the CDI Coordinator about review assignment volume
Initiate compliant physician queries when documentation is confusing, ambiguous or missing
Follow up with physicians to obtain immediate responses to queries using AHIMA practice briefs as guidance

Requirements

What you’ll need

Requires a University Degree and minimum 2-4 years of prior relevant experience; some roles may require graduate-level education Master’s or Doctorate degree (Relevant experience may be substituted for formal education or advanced degree)
One of the following: RN, MD, or MD Equivalent (MBBS), CCS
4+ years' experience providing direct patient care to acute and chronically ill patients in inpatient settings, critical care, ED or strong med-surg experience or substituted with prior experience
2+ years prior CDI experience
Familiarity with encoder and DRG assignment
Maintain current working knowledge of official coding guidelines and coding clinics
CCDS, CDIP preferred
ED/Critical care or case management; or inpatient acute care (referral hospital); strong critical thinking skills; strong interpersonal skills; strong clinical knowledge base
Coding, Case Management and/or Utilization Review experience preferred
Strong clinical understanding of disease process
Demonstrate critical thinking, 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; proficiency with EHR systems, CDI software systems and encoders

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
Flexible benefits package
Flexible work arrangements