Guidehouse
Clinical Documentation Integrity (CDI) Specialist - Remote
Guidehouse, Washington, District of Columbia, us, 20022
Clinical Documentation Integrity (CDI) Specialist - Remote
Join to apply for the
Clinical Documentation Integrity (CDI) Specialist - Remote
role at
Guidehouse . This is a remote position.
What You Will Do
The
Clinical Documentation Integrity 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 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 is captured for the level of service rendered to each patient, as well as ensuring compliant reimbursement of patient care services.
Duties and Responsibilities
Conduct comprehensive initial and follow-up concurrent reviews of medical records for assigned patients.
Identify opportunities to clarify incomplete or conflicting documentation and/or validate diagnosis.
Understand guiding principles of clinical validation and writing a compliant query.
Prepare compliant written queries for treating physicians following current ACDIS/AHMIA guidelines.
Identify principal diagnosis options, secondary diagnoses and significant procedures to assign working MS-DRG.
Establish and update DRG and expected Length of Stay during concurrent reviews.
Utilize appropriate UAB query template and follow 2022 ACDIS/AHMIA guidelines.
Ensure relevant clinical indicators are cited on query template.
Demonstrate knowledge of PSI, HAC, SOI/ROM and present on admission status.
Apply hospital‑approved clinical indicators for specified diagnoses.
Follow hospital procedures and policies regarding documentation, query escalation, DRG reconciliation.
Track physician query responses in medical record.
Maintain productivity and performance benchmarks for quality.
Use CDI application to process and prioritize work lists, capture review results, track queries.
Enter required data into CDI application and other systems for coders and auditors.
Use electronic coding references to assign working MS-DRG, SOI, and ROM.
Collaborate with coding team on ICD-10 coding and MS-DRG assignments.
Participate in DRG reconciliation process with coders.
Participate in department and hospital committees and task forces.
Contribute to a positive collaborative 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 with active license OR medical school graduation with MD OR RHIA, RHIT or CCS certification with active license.
Current/active RN, MD, RHIA, RHIT, CCS license.
2-4 years acute care inpatient hospital coding or CDI experience.
Familiarity with encoder and DRG assignment.
Maintain current knowledge of official coding guidelines and coding clinics.
Nice to Have
CCDS, CDIP certifications.
Strong clinical understanding of disease process.
Critical thinking, analytical skills, and problem solving.
Strong knowledge of medical terminology, anatomy, physiology, microbiology, and diseases.
Excellent communication skills.
Ability to converse with physicians in challenging scenarios.
Typing and computer skills; proficiency with EHR, CDI software, encoders.
Compensation
The annual salary range for this position is $68,000–$113,000. Compensation decisions depend on experience, training, licensure, and other factors.
Benefits
Medical, Rx, Dental & Vision Insurance
Personal and Family Sick Time & Company Paid Holidays
Variable incentive bonus opportunity
Parental Leave
401(k) Retirement Plan
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
About Guidehouse
Guidehouse is an Equal Opportunity Employer protected veterans, individuals with disabilities, and any other basis protected by law. Guidehouse will consider applicants with criminal histories in a manner consistent with applicable laws. If you require accommodation, contact Guidehouse Recruiting at 1‑571‑633‑1711 or RecruitingAccommodation@guidehouse.com.
Seniority level
Associate
Employment type
Full‑time
Job function
Health Care Provider
Business Consulting and Services
#J-18808-Ljbffr
Clinical Documentation Integrity (CDI) Specialist - Remote
role at
Guidehouse . This is a remote position.
What You Will Do
The
Clinical Documentation Integrity 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 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 is captured for the level of service rendered to each patient, as well as ensuring compliant reimbursement of patient care services.
Duties and Responsibilities
Conduct comprehensive initial and follow-up concurrent reviews of medical records for assigned patients.
Identify opportunities to clarify incomplete or conflicting documentation and/or validate diagnosis.
Understand guiding principles of clinical validation and writing a compliant query.
Prepare compliant written queries for treating physicians following current ACDIS/AHMIA guidelines.
Identify principal diagnosis options, secondary diagnoses and significant procedures to assign working MS-DRG.
Establish and update DRG and expected Length of Stay during concurrent reviews.
Utilize appropriate UAB query template and follow 2022 ACDIS/AHMIA guidelines.
Ensure relevant clinical indicators are cited on query template.
Demonstrate knowledge of PSI, HAC, SOI/ROM and present on admission status.
Apply hospital‑approved clinical indicators for specified diagnoses.
Follow hospital procedures and policies regarding documentation, query escalation, DRG reconciliation.
Track physician query responses in medical record.
Maintain productivity and performance benchmarks for quality.
Use CDI application to process and prioritize work lists, capture review results, track queries.
Enter required data into CDI application and other systems for coders and auditors.
Use electronic coding references to assign working MS-DRG, SOI, and ROM.
Collaborate with coding team on ICD-10 coding and MS-DRG assignments.
Participate in DRG reconciliation process with coders.
Participate in department and hospital committees and task forces.
Contribute to a positive collaborative 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 with active license OR medical school graduation with MD OR RHIA, RHIT or CCS certification with active license.
Current/active RN, MD, RHIA, RHIT, CCS license.
2-4 years acute care inpatient hospital coding or CDI experience.
Familiarity with encoder and DRG assignment.
Maintain current knowledge of official coding guidelines and coding clinics.
Nice to Have
CCDS, CDIP certifications.
Strong clinical understanding of disease process.
Critical thinking, analytical skills, and problem solving.
Strong knowledge of medical terminology, anatomy, physiology, microbiology, and diseases.
Excellent communication skills.
Ability to converse with physicians in challenging scenarios.
Typing and computer skills; proficiency with EHR, CDI software, encoders.
Compensation
The annual salary range for this position is $68,000–$113,000. Compensation decisions depend on experience, training, licensure, and other factors.
Benefits
Medical, Rx, Dental & Vision Insurance
Personal and Family Sick Time & Company Paid Holidays
Variable incentive bonus opportunity
Parental Leave
401(k) Retirement Plan
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
About Guidehouse
Guidehouse is an Equal Opportunity Employer protected veterans, individuals with disabilities, and any other basis protected by law. Guidehouse will consider applicants with criminal histories in a manner consistent with applicable laws. If you require accommodation, contact Guidehouse Recruiting at 1‑571‑633‑1711 or RecruitingAccommodation@guidehouse.com.
Seniority level
Associate
Employment type
Full‑time
Job function
Health Care Provider
Business Consulting and Services
#J-18808-Ljbffr