Clinical Documentation Quality & CDI Query Specialist

Second Wave Delivery Systems, LLC; Las Vegas (NV); On-site; USD 90,000 - 130,000; Full time

Job summary

Second Wave Delivery Systems, LLC seeks a Clinical Documentation Quality Reviewer to support accurate documentation, reimbursement, and care quality. The role focuses on quality measures (PSIs, CMS Core Measures, mortality) and identifying opportunities to improve documentation and coding.

As part of a collaborative team, the reviewer may draft physician queries, work with DRG validation, and support provider education while ensuring AHIMA/ACDIS compliance and neutrally documenting findings.

Qualifications

• Prior experience as a Clinical Documentation Improvement Specialist in a hospital setting.
• Experience with quality measure review (PSIs, mortality, CMS Core Measures) preferred.
• Minimum five years of hospital experience and/or documentation improvement expertise.
• Experience with EMR environments and regulatory standards.

Responsibilities

• Review inpatient records flagged for PSIs to validate documentation or coding opportunities.
• Review mortality cases to ensure accurate severity and risk adjustment.
• Review CMS Core Measures to identify documentation gaps.
• Recommend coding changes or physician queries when documentation is insufficient.
• Track and report findings to support client reporting and provider education.
• Support CDI query team by drafting and issuing compliant physician queries when volume allows.

Skills

Quality review

EMR experience

Query writing

Clinical terminology

Communication

Education

Bachelor’s degree or equivalent experience

Tools

3M Encoder Systems

Job description

Second Wave Delivery Systems, LLC seeks a Clinical Documentation Quality Reviewer to support accurate documentation, reimbursement, and care quality. The role focuses on quality measures (PSIs, CMS Core Measures, mortality) and identifying opportunities to improve documentation and coding.

As part of a collaborative team, the reviewer may draft physician queries, work with DRG validation, and support provider education while ensuring AHIMA/ACDIS compliance and neutrally documenting findings.