Clinical Documentation Integrity - Second Level Reviewer

University of Miami; Town of Florida (NY); On-site; USD 70,000 - 90,000; Full time

Benefits offered by this job

Medical Insurance

Dental Insurance

Tuition Remission

Comprehensive Benefits Package

Job summary

The University of Miami seeks a Clinical Documentation Integrity (CDI) Second Level Reviewer to perform complex secondary case reviews and ensure high-quality documentation in support of hospital initiatives and regulatory compliance. The ideal candidate will have a Bachelor's degree and clinical experience.

This role involves collaboration with healthcare teams and a commitment to improving clinical documentation accuracy. Benefits include competitive salaries and a comprehensive healthcare package.

Qualifications

• Four-year/bachelor’s degree required; graduate degree preferred.
• Current RN or MD required; CCDS or CDIP certification required.
• At least three years recent inpatient clinical documentation improvement experience required.
• Extensive clinical knowledge and understanding of disease management required.

Responsibilities

• Perform complex secondary case reviews to improve provider documentation.
• Ensure clinical documentation reflects accurate level of care and compliance with regulations.
• Complete quality reviews focusing on patient safety metrics.
• Identify trends for documentation improvement using critical thinking.

Skills

Clinical Documentation Improvement

Critical Thinking

ICD-10-CM/PCS proficiency

Quality review experience

Communication Skills

Education

Bachelor's degree in related field

Graduate degree in Healthcare Administration or related field

Tools

CDI software

Microsoft Office

3M 360 Encompass

Job description

We are looking for a Clinical Documentation Integrity (CDI) Second Level Reviewer to perform high-level, complex, secondary case reviews to facilitate and obtain appropriate provider documentation for clinical conditions or procedures. The role supports accurate, high‑quality clinical documentation to support hospital initiatives and regulatory compliance.

Responsibilities

• Ensures accuracy, completeness, and quality of clinical information used for measuring and reporting physician and hospital outcomes.
• Performs high‑level, complex, timely secondary case reviews concurrently and retrospectively to identify potential gaps or opportunities to improve provider documentation.
• Ensures clinical documentation accurately reflects the level of care rendered, severity of illness, risk of mortality and clinical validation (in compliance with government and other regulations).
• Applies advanced knowledge of CMS star rating, Vizient, and US News and World Report risk‑adjustment systems to identify clinical documentation improvement opportunities.
• Completes quality reviews focused on CDI quality elements such as Mortality, Hospital Acquired Conditions (HAC) and other publicly reported patient quality or safety metrics (i.e. AHRQ Patient Safety Indicators).
• Identifies trends and key areas for improvement in querying, coding, and documentation integrity.
• Demonstrates proficiency with ICD‑10‑CM/PCS, APR‑DRG, and MS‑DRG by providing information regarding clinical documentation opportunities, coding and DRG issues, as well as performance improvement methodologies.
• Recognizes opportunities for documentation improvement using strong critical‑thinking skills and sound judgment in decision making, keeping integrity and compliance at the forefront of considerations in addition to outcomes, reimbursement and regulatory requirements.
• Facilitates high‑quality documentation by utilizing queries that are effective, clear, concise, and compliant in accordance with the latest AHIMA/ACDIS Query Practice Brief.
• Makes recommendations for possible refinement of principal diagnosis, secondary diagnoses, and/or procedures based on clinical data to facilitate appropriate DRG assignment.
• Records review findings and other data elements accurately into CDI software and other data mechanisms to support data integrity for reporting.
• Effectively and appropriately communicates and collaborates with providers, HIM/coding, quality, CDI and other members of the healthcare team.
• Assists with concurrent and retrospective CDI case reviews, quality audits, and education as deemed necessary by CDI leadership.
• Works independently; demonstrates effective time management and prioritization of tasks.
• Participates in meetings, including providing feedback and identifying trends and opportunities, presentations for educational opportunities, and any other needs identified by the CDI leaders.
• Assumes responsibility for professional development through participation at workshops, conferences and/or in‑services and maintains appropriate records of participation.
• Participates in departmental and organization projects, task forces, and/or committees as needed.
• Complies with and ensures adherence to HIPAA and Code of Conduct policies.

Education

Four (4) year/bachelor’s degree required; BSN/BS/BA in related field required; graduate degree in Healthcare Administration, Informatics, Nursing, Leadership, Education or related field preferred.

Certification and Licensing

Current RN or MD required; CCDS or CDIP certification required; coding certification (CCS, CIC or CPC) preferred.

Experience

At least three (3) years recent inpatient clinical documentation improvement (CDI) experience required.

Demonstrated extensive clinical knowledge, critical‑thinking skills, and understanding of disease processes, pathophysiology, and disease management/treatment required.

At least three (3) years of direct patient care clinical experience in a hospital setting preferred.

Proficiency with ICD‑10‑CM/PCS, APR‑DRG, and MS‑DRG required.

At least one (1) year experience with mortality, PSI, HAC or other quality‑focused reviews required.

Knowledge of Vizient, Premier, US News and World Report, CMS star rating or similar risk‑adjustment methodologies highly preferred.

Prior experience in an academic medical center (AMC) or large health system preferred.

Proficiency with Microsoft Office (Excel, PowerPoint, Word, Outlook) required.

Proficiency with CDI software and encoder required. Experience with 3M 360 Encompass preferred.

Excellent written and verbal communication skills; ability to write concisely and effectively when communicating with providers.

Benefits

The University of Miami offers competitive salaries and a comprehensive benefits package including medical, dental, tuition remission and more.

UHealth – University of Miami Health System, South Florida’s only university‑based health system, provides leading‑edge patient care powered by groundbreaking research and medical education at the Miller School of Medicine. As an academic medical center, we proudly serve South Florida, Latin America and the Caribbean.

The University of Miami is an Equal Opportunity Employer. Applicants and employees are protected from discrimination based on categories protected by Federal law.

Job Status: Full time
Employee Type: Staff