Clinical Documentation Integrity Specialist

🕒 September 23

🇺🇸 United States – Remote

💵 $68k - $113k / year

⏰ Full Time

🟢 Junior

🟡 Mid-level

🏥📝 Medical Writer

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Guidehouse

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 2018

🏥 Healthcare

🎖️ Defense

📦 Logistics

💰 Grant on 2023-02

Healthcare • Defense • Logistics

Guidehouse is a global consultancy offering advisory, digital, and managed services across commercial and public sectors. It is purpose-built to support industries such as national security, financial services, healthcare, energy, and infrastructure. Guidehouse collaborates with leaders to navigate complexity and drives transformational changes that impact the future. Their expertise spans data analytics, digital technologies, risk management, and more, with a strong emphasis on sustainability and innovation.

📋 Description

• Conduct comprehensive initial and follow-up concurrent reviews of medical records • Identify opportunities to clarify incomplete or conflicting documentation and validate diagnoses • Prepare compliant written queries for treating physicians following ACDIS/AHIMA guidelines • Identify principal and secondary diagnoses and significant procedures to assign working MS-DRG • Establish and update working DRG based on record documentation and expected length of stay • Use approved query templates and cite relevant clinical indicators • Apply knowledge of PSI, HAC, SOI/ROM, and present-on-admission status • Follow hospital procedures for documentation requirements, query escalation, and DRG reconciliation • Track physician query responses in the medical record • Maintain productivity and quality performance benchmarks • Use CDI applications to prioritize worklists, capture review results, and track queries • Enter required data to support final MS-DRG, SOI, and ROM assignment • Use electronic coding references, Official Coding Guidelines, and Coding Clinic • Collaborate with the Coding team on ICD-10 coding, MS-DRG assignment, and queries • Participate in DRG reconciliation and departmental committees or task forces • Contribute to a positive collaborative work environment • Comply with HIPAA and code of conduct policies

🎯 Requirements

• Bachelor’s degree (Relevant experience may be substituted for formal education or advanced degree) • At least one of the following: RN, MD or MD Equivalent, RHIA, RHIT, CCS, with a current/active license • 2+ 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 • CCDS or CDIP certification preferred • Strong clinical understanding of disease process • Critical thinking, analytical skills, and ability to resolve problems • Strong knowledge of medical terminology, anatomy, physiology, microbiology, and disease processes • Excellent communication skills • Ability to converse with physicians in difficult scenarios • Strong typing and computer skills • Proficiency with EHR systems, CDI software systems and encoders

🏖️ Benefits

• Medical, Rx, Dental & Vision Insurance • Personal and Family Sick Time & Company Paid Holidays • Discretionary variable incentive bonus may be available • 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 • Flexible benefits package

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