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 .
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 the coding team to ensure that clinical information in the medical record is present and accurate so that 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.
Duties And Responsibilities
Conduct comprehensive initial and follow‑up concurrent reviews of medical records for assigned patients within the defined time frame, frequency and prioritization of the CDI team.
Identify opportunities to clarify incomplete or conflicting documentation and/or to validate diagnosis in the medical record.
Understand the guiding principles of clinical validation and write a compliant query.
Prepare a compliant written query for the responsible treating physician, following the most current ACDIS/AHMIA Guidelines.
Identify principal diagnosis options, secondary diagnoses and significant procedures to assign working MS‑DRG.
Establish a working DRG and update it based on record documentation during concurrent reviews to reflect current expected length of stay as appropriate.
Utilize the appropriate UAB query template and follow 2022 ACDIS/AHMIA Guidelines.
Ensure 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.
Demonstrate knowledge of PSI’s, HAC’s, SOI/ROM as well as present on admission status.
Apply and use hospital approved clinical indicators for specified diagnoses appropriately.
Follow hospital specific procedures and policies regarding 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.
Use the CDI application to process and prioritize daily work lists, capture results of record reviews and track queries and responses.
Enter all required data into CDI application and/or other systems so coders and CDI/Coding auditors can determine disposition of concurrent queries to assign the final MS‑DRG as well as SOI and ROM.
Use electronic coding references to code and assign working MS‑DRG along with SOI and ROM; reference official coding guidelines and coding clinic for accurate code assignment.
Collaborate with the coding team on questions related to ICD‑10 coding and/or MS‑DRG assignment, and participate in preparation of concurrent and/or retrospective queries.
Participate in DRG reconciliation process in a timely and thorough manner with coders.
Participate in departmental and hospital committees, assigned task forces, and service line 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 an accredited School of Nursing.
Bachelor’s degree in a health‑related field and/or Master’s with a current/active license, OR graduation from an 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 equivalent, RHIA, RHIT, CCS, with a current/active license.
2–4 years of 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 processes.
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.
Additional Information Remote location. The annual salary range for this position is
$68,000.00 – $113,000.00 . Compensation decisions depend on skill set, experience, training, clearances, licensure, certifications, and other business factors.
Benefits
Medical, Rx, Dental & Vision Insurance
Personal and Family Sick Time & Company Paid Holidays
Eligibility 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
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 or ordinance. All communication will be sent from Guidehouse email domains only. Guidehouse will never charge a fee or require a money transfer at any stage of the recruitment process and does not collect fees from educational institutions for recruitment events. If you have visited our website for employment information or to apply, and you require an accommodation, please contact Guidehouse Recruiting at 1‑571‑633‑1711 or via email at RecruitingAccommodation@guidehouse.com. All information you provide will be kept confidential and used only as required to provide accommodation. Guidehouse is not responsible for losses incurred from applicant dealings with unauthorized third parties. If any person or organization demands money related to a job opportunity with Guidehouse, report it to Guidehouse’s Ethics Hotline.
Application To apply, submit your application through the Guidehouse careers portal. The role is open for candidates in Washington, D.C.; however, the position is remote and open to qualified candidates nationwide.
#J-18808-Ljbffr
Clinical Documentation Integrity (CDI) Specialist - Remote
role at
Guidehouse .
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 the coding team to ensure that clinical information in the medical record is present and accurate so that 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.
Duties And Responsibilities
Conduct comprehensive initial and follow‑up concurrent reviews of medical records for assigned patients within the defined time frame, frequency and prioritization of the CDI team.
Identify opportunities to clarify incomplete or conflicting documentation and/or to validate diagnosis in the medical record.
Understand the guiding principles of clinical validation and write a compliant query.
Prepare a compliant written query for the responsible treating physician, following the most current ACDIS/AHMIA Guidelines.
Identify principal diagnosis options, secondary diagnoses and significant procedures to assign working MS‑DRG.
Establish a working DRG and update it based on record documentation during concurrent reviews to reflect current expected length of stay as appropriate.
Utilize the appropriate UAB query template and follow 2022 ACDIS/AHMIA Guidelines.
Ensure 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.
Demonstrate knowledge of PSI’s, HAC’s, SOI/ROM as well as present on admission status.
Apply and use hospital approved clinical indicators for specified diagnoses appropriately.
Follow hospital specific procedures and policies regarding 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.
Use the CDI application to process and prioritize daily work lists, capture results of record reviews and track queries and responses.
Enter all required data into CDI application and/or other systems so coders and CDI/Coding auditors can determine disposition of concurrent queries to assign the final MS‑DRG as well as SOI and ROM.
Use electronic coding references to code and assign working MS‑DRG along with SOI and ROM; reference official coding guidelines and coding clinic for accurate code assignment.
Collaborate with the coding team on questions related to ICD‑10 coding and/or MS‑DRG assignment, and participate in preparation of concurrent and/or retrospective queries.
Participate in DRG reconciliation process in a timely and thorough manner with coders.
Participate in departmental and hospital committees, assigned task forces, and service line 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 an accredited School of Nursing.
Bachelor’s degree in a health‑related field and/or Master’s with a current/active license, OR graduation from an 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 equivalent, RHIA, RHIT, CCS, with a current/active license.
2–4 years of 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 processes.
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.
Additional Information Remote location. The annual salary range for this position is
$68,000.00 – $113,000.00 . Compensation decisions depend on skill set, experience, training, clearances, licensure, certifications, and other business factors.
Benefits
Medical, Rx, Dental & Vision Insurance
Personal and Family Sick Time & Company Paid Holidays
Eligibility 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
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 or ordinance. All communication will be sent from Guidehouse email domains only. Guidehouse will never charge a fee or require a money transfer at any stage of the recruitment process and does not collect fees from educational institutions for recruitment events. If you have visited our website for employment information or to apply, and you require an accommodation, please contact Guidehouse Recruiting at 1‑571‑633‑1711 or via email at RecruitingAccommodation@guidehouse.com. All information you provide will be kept confidential and used only as required to provide accommodation. Guidehouse is not responsible for losses incurred from applicant dealings with unauthorized third parties. If any person or organization demands money related to a job opportunity with Guidehouse, report it to Guidehouse’s Ethics Hotline.
Application To apply, submit your application through the Guidehouse careers portal. The role is open for candidates in Washington, D.C.; however, the position is remote and open to qualified candidates nationwide.
#J-18808-Ljbffr