Clinical Documentation Integrity Specialist

Guidehouse

. Conduct comprehensive initial and follow-up concurrent reviews of medical records .

Posted 9/23/2026full-timeRemote • United StatesJuniorMid-Level💰 $68,000 - $113,000 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in medical record reviews, MS-DRG assignment, and compliance with coding guidelines. Proficient in utilizing CDI applications and EHR systems to enhance documentation accuracy and support clinical decision-making.

Highest-signal resume keywords

MS-DRG AssignmentICD-10 CodingCDI ApplicationsCCDS or CDIP CertificationClinical Documentation Improvement

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Medical Record ReviewDRG ReconciliationQuery PreparationCoding Guidelines KnowledgeMedical TerminologyAnatomy and PhysiologyCritical ThinkingAnalytical SkillsDisease Process UnderstandingTyping Skills

Soft Skills

Excellent Communication SkillsProblem-Solving AbilityCollaborationInterpersonal Skills

Tools & Technologies

EHR SystemsCDI Software SystemsEncoders

Certifications & Qualifications

RNMDRHIARHITCCSCCDSCDIP

Industry Keywords

ACDISAHIMAHIPAAAcute CareInpatient Hospital CodingOfficial Coding GuidelinesCoding ClinicPresent-on-Admission StatusPSIHAC

About the role

Key responsibilities & impact

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

What you’ll need

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

Comp & perks

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