Clinical Documentation Integrity (CDI) Specialist - 2nd Level Reviewer- Remote

Guidehouse; United States; Remote; USD 55,000 - 65,000; Full time

Job summary

Join a leading business consulting firm as a Clinical Documentation Integrity (CDI) Specialist - 2nd Level Reviewer, where you will play a crucial role in enhancing clinical documentation quality and accuracy. This fully remote position involves collaboration with healthcare professionals to ensure clinical documentation meets compliance standards, engaging in troubleshooting coding discrepancies, and providing education based on findings. Ideal candidates will possess relevant degrees, certifications, and substantial experience in clinical documentation, with strong analytical and communication skills.

Qualifications

• BSN, ADN, MD, or similar health-related degree required.
• 4-6 years of relevant experience in CDI or inpatient coding quality review.
• CCDS or CDIP certification is preferred.

Responsibilities

• Conduct comprehensive secondary clinical chart reviews.
• Collaborate with CDI educators and resolve discrepancies.
• Enhance documentation quality through queries and education.

Skills

Clinical documentation

Critical thinking

Communication skills

Data analysis

Education

BSN, ADN, MD or equivalent

CCDS or CDIP certification (preferred)

Job description

Clinical Documentation Integrity (CDI) Specialist - 2nd Level Reviewer- Remote

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The CDI Specialist- 2nd Level Reviewer responsibilities include comprehensive secondary clinical chart reviews to identify potential missed opportunities for documentation clarification, act as a liaison between coding and CDI to resolve DRG or other code discrepancies, collaborate with CDI educator to educate CDI team based on opportunities identified in second level reviews and work directly with clinicians and providers to improve the overall quality and completeness of documentation through the query process and/or provider education. The Clinical Documentation Integrity Second Level Reviewer will collaborate closely with Coders, Coding Educators, Coding Quality Auditors, Case managers, Quality Department and Providers to assure documentation is clinically appropriate, accurately reflects the severity of illness and risk of mortality for the patient and is reflective of current CMS or other regulatory standards. This position is 100% remote. Analyzes and interprets clinical data to identify gaps, inconsistencies, and/or opportunities for improvement in the clinical documentation and queries the provider using concurrent query process following ACDIS/AHIMA Guidelines for Compliant Query Writing. Completes comprehensive, clinical secondary reviews of targeted patient populations to include cases with DRG and/or code discrepancies; mortality reviews to ensure documentation supports risk of mortality; hospital acquired conditions (HACs), patient safety indicators (PSIs) or other top priority diagnosis as identified for potential missed opportunities to clarify documentation or clinically validate a diagnosis. Acts as a liaison between the Coding Department and the Clinical Documentation Specialist to reconcile discrepancies in code and/or DRG assignment. Communicates findings of secondary reviews to respective Clinical Documentation Specialist for follow-up and query initiation. Collaborates with CDI educator/quality auditor when educational needs are identified from second level reviews. Documents and tracks second level reviews and results. Shares this information with staff at monthly CDI team meeting. Collaborative interaction with physicians and/or other clinicians to enhance understanding of the CDI program goals; ensure the medical record can be coded accurately in order to accurately reflect patient severity of illness and risk of mortality. Requirements include graduation from accredited School of Nursing with BSN, ADN OR Graduation from accredited medical school with MD or equivalent OR Bachelor's or Master's Degree in health-related field; currently licensed as a Registered Nurse, MD or MD equivalent OR Credentialed Medical Coder through AHIMA with current CCS, RHIA or RHIT credential and CDIP or CCDS; 4-6 years previous relevant experience in clinical documentation, or CDI second level review or inpatient coding quality review and/or DRG validation with a strong understanding of disease processes, clinical indications and treatments; provider documentation requirements to reflect severity of illness, risk of mortality and support the diagnosis/procedures performed for accurate clinical coding and billing according the rules of Medicare, Medicaid, and commercial payors as well as a solid understanding of hospital acquired conditions (HAC’s), patient safety indicators (PSI’s) and mortality models. Must maintain credentials while employed. Preferred qualifications include CCDS or CDIP certification, strong clinical and critical thinking skillset, experience with encoder and DRG assignments (MS and APR), maintains working knowledge of Official Coding Guidelines, Coding Clinic and federal updates to the DRG system, ability to conduct meaningful conversations and/or presentations with providers in all situations, excellent communication skills, with ability to listen and understand client request and needs while employing tact and effectiveness.

Seniority level

• Seniority level

  Mid-Senior level

Employment type

• Employment type

  Full-time

Job function

• Job function

  Other

• Industries

  Business Consulting and Services

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