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Clinical Documentation Improvement Specialist

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Job ID 21REQ-02762 Location Chicago, Illinois Company Name Xtend Healthcare, LLC

Xtend Healthcare, LLC, provides entirely revenue cycle-based projects which range from complete business office outsourcing to A/R legacy cleanup, self-pay and third-party CBO safety net engagements as well as coding and consulting engagements. We serve clients of all types and sizes in all 50 states -- from critical-access hospitals to those with more than 2,000 patient beds, and from individual facilities to multi-hospital, university-affiliated health systems as well as physician's revenue cycle business.

In 2015, Xtend was acquired by Navient, the nation's leading loan management, servicing, and asset recovery company. By joining forces with Navient, the Xtend team will be bolstered by the strength, stability, and resources of an industry leader, and leverage the parent company's large-scale business process outsourcing capabilities.


The Clinical Documentation Improvement Specialist (CDIS) is responsible for the concurrent and retrospective (when applicable) review of medical records to assure appropriateness of care, accuracy of documentation, validation of severity of illness and quality of services provided.   The CDIS will audit charts for appropriateness of admission, continued stay, compliance to hospital metrics and appropriate documentation based on diagnosis and severity of illness.  The Quality CDIS will interact with physicians, nurses and other professionals regarding documentation and actively participate in team meetings to improve physician and clinical staff chart documentation.   Patient charts not meeting approved guidelines will be selected for peer review and follow-up.

The CDIS must exhibit expertise in all aspects of health information management with knowledge and working knowledge of coding (ICD-10-CM & PCS, CPT, MS-DRGS, APRG-DRGs, HCCs) for acute care hospitals, skill nursing facilities, swing beds, hospice, and inpatient rehab facilities.   A high level of knowledge of physician specialty medical practices is also a plus. Understanding and communicating differences between Medicare Part A and Part B guidelines and how they impact MS-DRGs and APR-DRGs is required. 


1.   Applies the skills necessary to concurrently/retrospectively review (initial & extended stay) charts, improve documentation based on diagnosis and clinical findings with:

  • Accurate and timely record reviews.
  • Recognizing problems identified during chart review and refer appropriate cases to peer review.
  • Formulating clinically credible documentation clarifications in the form of queries
  • Timely follow up on all cases especially those with clinical documentation clarifications
  • Communicating with others clinical or non-clinical staff/MDs to resolve discrepancies
  • Understanding and communicating differences between Medicare Part A and Part B guidelines and how they impact MS-DRGs and APR-DRGs.

2. Generates reports internally on required functions.   

  • (e.g., productivity, core measures, outcomes metric, etc., utilizing report Formats to display the use of aggregate and trended data.).

3.  Effective and appropriate communication with physicians and nurses. 

4.  Participates in internal and external Team Meetings.  

  • -Demonstrates professionalism when communicating with CDI and HIM staff in resolving discrepancies.


  • Associate degree (Nursing degree or specialized HIM degree (RHIA or RHIT) HIM Professional coder credentialed or credential eligible.)
  • Three (3) years’ experience in the CDI and/or health information management area of healthcare.  This should include hospital with physician practice.  (Additional equivalent education above the required minimum may for the required level of experience)
  • Working knowledge of ICD10 CM & PCS, CPT, MS-DRGs, APR-DRGs
  • Electronic health record (EHR) expertise, including knowledge of a variety of vendors
  • Must be credentialed through AHIMA and/or ACDIS at a minimum


  • An understanding of healthcare billing practices and compliant claims preparation for both governmental and commercial payers.
  • Knowledge of HCC’s is preferred
  • Experience with encoders; experience with CAC software
  • Experience with Case Management, Utilization Review
  • A plus if: CCS, CCDIS, nationally recognized ICD-10-CM and PCS trainer National HIM certifications from the AAPC or AHIMA, or CCDS from ACDIS
  • Working knowledge of CDI “best practices.”
  • Able to interact positively with clients and understand their needs in the HIM and medical records of healthcare

All offers of employment are contingent on standard background checks. Navient and certain of its affiliated companies are federal, state and/or local government contractors. Should this position support a Federal Government contract, now or in the future, the successful candidate will be subject to a background check conducted by the U.S. Government to determine eligibility and suitability for federal contract employment for public trust or sensitive positions. Positions that support state and/or local contracts also may require additional background checks to determine eligibility and suitability.

EOE Race/Ethnicity/Sex/Disability/Protected Vet/Sexual Orientation/Gender Identity. Navient Corporation and its subsidiaries are not sponsored by or agencies of the United States of America.

Navient is a drug free workplace.

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  • Comprehensive Health, Dental and Vision Plans

  • 401K with Company Match (after 6 months)

  • Tuition Reimbursement

  • Generous PTO Starting at 15 Days and 8 Paid Holidays

  • Paid Parental Leave and Adoption Assistance

  • Employee Stock Purchase Plan

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