Guidehouse
Clinical Documentation Integrity (CDI) Specialist - Remote
Guidehouse, Washington, District of Columbia, us, 20022
Clinical Documentation Integrity (CDI) Specialist - Remote
Overview
The
Clinical Documentation Integrity (CDI) Specialist
reviews and analyzes health records to identify opportunities to clarify relevant diagnoses and procedures for distinct patient encounters. Works collaboratively with providers, other health care professionals and the coding team to ensure that clinical information in the medical record is present and accurate so that the appropriate utilization, clinical severity, outcomes, and quality are captured for the level of service rendered to each patient, as well as ensuring compliant reimbursement of patient care services.
Responsibilities
Conducts comprehensive initial and follow-up concurrent reviews of medical records for assigned patients in the time frame, frequency and prioritization as defined for the CDI team
Identifies opportunities to clarify incomplete or conflicting documentation and/or to validate diagnosis in the medical record
Understands the guiding principles of clinical validation and writing a compliant query
Prepares a compliant written query for responsible treating physician, following the most current ACDIS/AHMIA Guidelines to Achieving a Compliant Query Process
Identifies principal diagnosis options, secondary diagnoses and significant procedures in order to assign working MS-DRG
Establishes a working DRG and updates DRG based on record documentation during concurrent reviews to reflect current expected Length of Stay as appropriate
Utilizes the appropriate UAB query template and follows 2022 ACDIS/AHIMA Guidelines to Achieving a Compliant Query Process
Ensures relevant and/or approved clinical indicators specific to the patient and the clinical record are cited on the query template
Choices provided on the query must reflect reasonable conclusions specific to the patient and the clinical record
Demonstrates knowledge of Patient Safety Indicators (PSI), Hospital Acquired Conditions (HAC), Severity of Illness & Risk of Mortality (SOI/ROM) as well as present on admission status
Ability to appropriately apply and use hospital approved clinical indicators for specified diagnoses
Follow hospital procedures and policies with regards to documentation requirements, query escalation, DRG reconciliation and other duties
Track physician query response documented in the medical record
Maintain productivity and established performance benchmarks for quality
Ensure competency in use of CDI application to process and prioritize daily work lists, capture results of record reviews, track queries and query responses
Enter all required data into CDI application and/or other systems to enable coders and CDI/Coding auditors to determine disposition of concurrent queries in order to assign the final MS-DRG as well as SOI and ROM
Ensure competency in use of electronic coding references to code and assign working MS-DRG along with SOI and ROM; reference related Official Coding Guidelines and Coding Clinic for accurate code assignment
Collaborate with Coding team on any questions related to ICD-10 coding and/or MS-DRG assignment, involved in the preparation of concurrent and/or retrospective queries
Participate in DRG reconciliation process in a collaborative, timely, and thorough manner with coders
Participate in departmental and hospital committees, assigned task forces, including service line assignment meetings as requested
Contribute to a positive and collaborative working environment
Comply with HIPAA and code of conduct policies
What You Will Need
Graduation from accredited School of Nursing
Bachelor’s degree in health-related field and/or Master’s required with a current/active license OR Graduation from accredited medical school with MD OR RHIA, RHIT or CCS Certification with a current/active license
At least one of the following: RN, MD or MD Equivalent, RHIA, RHIT, CCS, with a current/active license
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
What Would Be Nice To Have
CCDS, CDIP 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
Excellent communication skills, employing tact and effectiveness
Ability to converse with physicians in sometimes difficult scenarios
Strong typing and computer skills; proficiency with EHR systems, CDI software systems and encoders
Salary:
The annual salary range for this position is $68,000.00-$113,000.00. Compensation decisions depend on a wide range of factors, including but not limited to skill sets, experience and training.
What We Offer
Medical, Rx, Dental & Vision Insurance
Personal and Family Sick Time & Company Paid Holidays
Potential discretionary variable incentive bonus
Parental Leave
401(k) Retirement Plan
Basic Life & Supplemental Life
Health Savings Account and related benefits
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
About Guidehouse
Guidehouse is an Equal Opportunity Employer – Protected Veterans, Individuals with Disabilities or any other basis protected by law, ordinance, or regulation. Guidehouse will consider qualified applicants with criminal histories in a manner consistent with applicable law.
If you require an accommodation, please contact Guidehouse Recruiting at 1-571-633-1711 or RecruitingAccommodation@guidehouse.com. All information will be kept confidential and used only to provide needed reasonable accommodation.
Guidehouse does not accept unsolicited resumes from search firms or staffing agencies. All unsolicited resumes will be considered the property of Guidehouse.
#J-18808-Ljbffr
The
Clinical Documentation Integrity (CDI) Specialist
reviews and analyzes health records to identify opportunities to clarify relevant diagnoses and procedures for distinct patient encounters. Works collaboratively with providers, other health care professionals and the coding team to ensure that clinical information in the medical record is present and accurate so that the appropriate utilization, clinical severity, outcomes, and quality are captured for the level of service rendered to each patient, as well as ensuring compliant reimbursement of patient care services.
Responsibilities
Conducts comprehensive initial and follow-up concurrent reviews of medical records for assigned patients in the time frame, frequency and prioritization as defined for the CDI team
Identifies opportunities to clarify incomplete or conflicting documentation and/or to validate diagnosis in the medical record
Understands the guiding principles of clinical validation and writing a compliant query
Prepares a compliant written query for responsible treating physician, following the most current ACDIS/AHMIA Guidelines to Achieving a Compliant Query Process
Identifies principal diagnosis options, secondary diagnoses and significant procedures in order to assign working MS-DRG
Establishes a working DRG and updates DRG based on record documentation during concurrent reviews to reflect current expected Length of Stay as appropriate
Utilizes the appropriate UAB query template and follows 2022 ACDIS/AHIMA Guidelines to Achieving a Compliant Query Process
Ensures relevant and/or approved clinical indicators specific to the patient and the clinical record are cited on the query template
Choices provided on the query must reflect reasonable conclusions specific to the patient and the clinical record
Demonstrates knowledge of Patient Safety Indicators (PSI), Hospital Acquired Conditions (HAC), Severity of Illness & Risk of Mortality (SOI/ROM) as well as present on admission status
Ability to appropriately apply and use hospital approved clinical indicators for specified diagnoses
Follow hospital procedures and policies with regards to documentation requirements, query escalation, DRG reconciliation and other duties
Track physician query response documented in the medical record
Maintain productivity and established performance benchmarks for quality
Ensure competency in use of CDI application to process and prioritize daily work lists, capture results of record reviews, track queries and query responses
Enter all required data into CDI application and/or other systems to enable coders and CDI/Coding auditors to determine disposition of concurrent queries in order to assign the final MS-DRG as well as SOI and ROM
Ensure competency in use of electronic coding references to code and assign working MS-DRG along with SOI and ROM; reference related Official Coding Guidelines and Coding Clinic for accurate code assignment
Collaborate with Coding team on any questions related to ICD-10 coding and/or MS-DRG assignment, involved in the preparation of concurrent and/or retrospective queries
Participate in DRG reconciliation process in a collaborative, timely, and thorough manner with coders
Participate in departmental and hospital committees, assigned task forces, including service line assignment meetings as requested
Contribute to a positive and collaborative working environment
Comply with HIPAA and code of conduct policies
What You Will Need
Graduation from accredited School of Nursing
Bachelor’s degree in health-related field and/or Master’s required with a current/active license OR Graduation from accredited medical school with MD OR RHIA, RHIT or CCS Certification with a current/active license
At least one of the following: RN, MD or MD Equivalent, RHIA, RHIT, CCS, with a current/active license
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
What Would Be Nice To Have
CCDS, CDIP 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
Excellent communication skills, employing tact and effectiveness
Ability to converse with physicians in sometimes difficult scenarios
Strong typing and computer skills; proficiency with EHR systems, CDI software systems and encoders
Salary:
The annual salary range for this position is $68,000.00-$113,000.00. Compensation decisions depend on a wide range of factors, including but not limited to skill sets, experience and training.
What We Offer
Medical, Rx, Dental & Vision Insurance
Personal and Family Sick Time & Company Paid Holidays
Potential discretionary variable incentive bonus
Parental Leave
401(k) Retirement Plan
Basic Life & Supplemental Life
Health Savings Account and related benefits
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
About Guidehouse
Guidehouse is an Equal Opportunity Employer – Protected Veterans, Individuals with Disabilities or any other basis protected by law, ordinance, or regulation. Guidehouse will consider qualified applicants with criminal histories in a manner consistent with applicable law.
If you require an accommodation, please contact Guidehouse Recruiting at 1-571-633-1711 or RecruitingAccommodation@guidehouse.com. All information will be kept confidential and used only to provide needed reasonable accommodation.
Guidehouse does not accept unsolicited resumes from search firms or staffing agencies. All unsolicited resumes will be considered the property of Guidehouse.
#J-18808-Ljbffr