Clinical Documentation Integrity; CDI Specialist - Remote

Clinical Documentation Integrity (CDI) Specialist – Remote

Apply for the Clinical Documentation Integrity (CDI) Specialist – Remote role at Guidehouse.

The Clinical Documentation Integrity Specialist reviews and analyzes health records to identify opportunities to clarify diagnoses and procedures for distinct patient encounters. The specialist 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, and to ensure compliant reimbursement of patient care services.

• 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 validate diagnosis in the medical record
• Understands the guiding principles of clinical validation and writing a compliant query
• Prepares a compliant written query for the 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 to assign a working MS‑DRG
• Establishes a working DRG and updates it 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
• Appropriately applies and uses hospital‑approved clinical indicators for specified diagnoses
• Follows hospital‑specific procedures and policies regarding documentation requirements, query escalation, DRG reconciliation and other duties
• Tracks physician query response documented in the medical record
• Maintains productivity and established performance benchmarks for quality
• Uses the CDI application to process and prioritize daily work lists, capture results of record reviews, track queries and query responses
• Enters all required data into the CDI application and/or other systems to enable coders and CDI/coding auditors to determine disposition of concurrent queries to assign the final MS‑DRG as well as SOI and ROM
• Uses electronic coding references to code and assign working MS‑DRG along with SOI and ROM; references official coding guidelines and Coding Clinic for accurate code assignment
• Collaborates with the 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
• Participates in the DRG reconciliation process in a collaborative,, and thorough manner with coders
• Participates in departmental and hospital committees, assigned task forces, including service‑line assignment meetings as requested
• Contributes to a positive and collaborative working environment
• Complies with HIPAA and code‑of‑conduct policies

• Bachelor’s degree (relevant experience may be substituted for formal education or an advanced degree)
• At least one of the following credentials and a current/active license: RN, MD or MD equivalent, RHIA, RHIT, CCS
• Two or more years of acute‑care inpatient hospital coding or CDI experience
• Familiarity with encoder and DRG assignment
• Current working knowledge of official coding guidelines and coding clinics

• CCDS or CDIP certification
• Strong clinical understanding of disease process
• Demonstrated critical thinking, analytical skills and problem‑solving ability
• Strong knowledge of…