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Second Wave Delivery Systems

Query Writer (Clinical Documentation Specialist)

Posted 21 days ago
$95000 - $120K per year
5-10 years experience
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AI Summary

The Query Writer is responsible for drafting and managing compliant physician queries to ensure accurate clinical documentation and appropriate reimbursement. They collaborate with medical directors and coding teams to resolve documentation ambiguities and maintain compliance with AHIMA and ACDIS standards.

The Query Writer plays a critical role in supporting Second Wave Delivery Systems’ mission to ensure accurate clinical documentation and appropriate reimbursement. This position is responsible for drafting, issuing, and managing compliant physician queries to clarify documentation, resolve coding ambiguities, and drive DRG and SOI accuracy. The Query Writer collaborates closely with DRG Validation Auditors, Medical Directors, and revenue cycle analysts to ensure documentation reflects the complete clinical picture of patient care.

Key Responsibilities:

  • Develop and issue compliant physician queries based on clinical indicators, coding guidelines, and documentation gaps.

  • Review medical records to identify opportunities for clarification that impact DRG assignment, SOI/ROM, and reimbursement integrity.

  • Ensure all queries adhere to AHIMA and ACDIS standards for compliance and neutrality.

  • Track and follow up on outstanding queries to ensure timely response and resolution.

  • Collaborate with CDI professionals and inpatient coders to align documentation with coding and regulatory requirements.

  • Maintain accurate records of query activity for audit and reporting purposes.

  • Participate in education initiatives for providers regarding documentation best practices.

  • Perform other duties as assigned. 

Qualifications:

  • Education and Experience:

    • Prior experience as a Clinical Documentation Improvement Specialist within a hospital setting.

    • Bachelor’s degree or equivalent experience required.

    • Clinical background or training as a Registered Nurse, Nurse Practitioner, Occupational Therapist, Physical Therapist, Physician Assistant, or Physician.

    • Demonstrated experience working in an Electronic Medical Record (EMR) environment.

    • Minimum of five years of recent hospital experience and/or verifiable documentation improvement expertise.

    • Proficiency with 3M Encoder Systems.

  • Knowledge, Skills, and Abilities

    • Strong understanding of coding guidelines, DRG assignment, and clinical terminology.

    • Excellent written communication skills for clear, compliant query development.

    • Ability to interpret clinical indicators and apply coding principles accurately.

    • Detail-oriented with strong organizational and follow-up skills.

    • Proficient in EHR systems and query management tools.

  • Key Competencies:

    • Compliance Focus: Adheres to regulatory standards and ethical query practices.

    • Collaboration: Works effectively with physicians, coders, and CDI teams.

    • Analytical Thinking: Identifies documentation gaps and interprets clinical data accurately.

    • Communication: Crafts clear, concise, and compliant queries.

Job Benefits

  • Health insurance
  • Vision insurance
  • Dental insurance
  • Life insurance
  • Retirement plan
  • Paid time off

Location

  • Remote

Compensation Range: $95,000 - $120,000

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