Job Description

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 Guidehouse

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