RN Clinical Documentation Second Level Reviewer (100%, days)

University of Washington; United States; Remote; USD 70,000 - 110,000; Full time

Job summary

An established industry player is seeking a dedicated RN Clinical Documentation Integrity Specialist to join their team. This role offers a unique opportunity to ensure high-quality standards in clinical documentation, focusing on risk adjustment and DRG accuracy. The position is fully remote, allowing for flexibility while contributing to a mission-driven organization. You will play a crucial role in reviewing medical records, collaborating with multidisciplinary teams, and promoting quality improvement initiatives. If you are passionate about enhancing patient care through meticulous documentation and have extensive nursing experience, this position could be your next career step.

Qualifications

• 6+ years of nursing experience in an acute inpatient hospital setting.
• 5+ years in Clinical Documentation Improvement with risk adjustment experience.

Responsibilities

• Review target DRGs for accuracy and completeness of clinical information.
• Collaborate with coding staff and compliance for Clinical Validation Denial appeals.

Skills

Clinical Documentation Improvement

Nursing Experience

Risk Adjustment

Medical and Surgical Care Knowledge

Education

Current WA RN License

Certification in CDI (CCDS, CDIP or CCS)

Job description

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RN Clinical Documentation Second Level Reviewer (100%, days)

Req #: 244821

Department: UW MEDICAL CENTER - CLINICAL DOCUMENTATION

Job Location: Remote/Hybrid

Posting Date: 04/09/2025

Closing Info: Open Until Filled

Shift: First Shift

UW MEDICAL CENTER – MONTLAKE has an outstanding opportunity for a Second Level Review Clinical Documentation Integrity Specialist (RN).

WORK SCHEDULE
Full-time day shift. The work is fully remote.

POSITION HIGHLIGHTS
Following established policies, procedures, and professional guidelines, the Second Level Review Clinical Documentation Integrity Specialist (SLR CDIS) provides industry expertise on focused accounts that are set by the direction of CDP leadership to ensure high quality standards are met for risk adjustment, DRG accuracy, SOI and ROM.

DEPARTMENT DESCRIPTION
The Clinical Documentation Integrity Program (CDIP) performs concurrent review of inpatient medical records to ensure provider documentation accurately reflects patient severity of illness (SOI), acuity of care needs, risk of mortality (ROM) and the quality of treatment provided. Team members also serve on various multidisciplinary committees promoting quality improvement and patient safety initiatives.

PRIMARY JOB RESPONSIBILITIES

1. Reviews target DRGs specified by CDP Manager, which is an evolving workflow. This review may focus on various elements including, but not limited to, CC/MCC capture rate and/or risk adjustment review and will be clarified by DRG.
2. Ensures that pertinent patient conditions and treatments are documented such that appropriate reimbursement is received for the level of acuity and service rendered to all patients using a DRG based payer (Medicare) methodology.
3. Verifies the accuracy and completeness of clinical information used for measuring and reporting outcomes related to patient care, physician practice and the medical center performance.
4. Participates in various projects and initiatives within the Clinical Documentation Program. Based on findings, department goals and initiatives and industry expectation, the SLR CDIS will participate in the education and evaluation of the CDI team.
5. Collaborates with medical records coding staff, patient financial services (PFS) and compliance for Clinical Validation Denial appeals.

REQUIREMENTS
Please apply only if you meet the listed requirements below.

1. Current WA RN License or compact RN license.
2. Minimum of 6 years of nursing experience in an acute inpatient hospital setting with in-depth knowledge of medical and surgical care. ER or ICU experience preferred.
3. Minimum of 5 years of experience in a Clinical Documentation Improvement role.
4. Risk adjustment experience required (Vizient and Elixhauser preferred).
5. Current Certification in CDI (CCDS, CDIP or CCS).

ABOUT UW MEDICAL CENTER-MONTLAKE
UW Medical Center is an acute care academic medical center located in Seattle with two campuses: Montlake and Northwest. As the No. 1 hospital in Seattle and Washington State since 2012 (U.S. News & World Report) and nationally ranked in seven specialties, UW Medical Center prides itself on compassionate patient care as well as its pioneering medical advances.

The UW Medical Center-Montlake campus is located on the edge of the beautiful UW campus which includes many amenities available to our staff as well as very convenient public transit options including the Sound Transit’s light rail station across the street.

Excellence. Exploration. Education. Become part of our team. Join our mission to make life healthier for everyone in our community.

ABOUT UW MEDICINE – WHERE YOUR IMPACT GOES FURTHER
UW Medicine is Washington’s only health system that includes a top-rated medical school and an internationally recognized research center. UW Medicine’s mission is to improve the health of the public by advancing medical knowledge, providing outstanding primary and specialty care to the people of the region, and preparing tomorrow’s physicians, scientists and other health professionals.

All across UW Medicine, our employees collaborate to perform the highest quality work with integrity and compassion and to create a respectful, welcoming environment where every patient, family, student and colleague is valued and honored. Nearly 29,000 healthcare professionals, researchers, and educators work in the UW Medicine family of organizations that includes: Harborview Medical Center, UW Medical Center - Montlake, UW Medical Center - Northwest, Valley Medical Center, UW Medicine Primary Care, UW Physicians, UW School of Medicine, and Airlift Northwest.

Find your place at Washington’s only integrated health system devoted to improving the health of all people. Join our mission to make life healthier for everyone in our community.

Committed to attracting and retaining a diverse staff, the University of Washington will honor your experiences, perspectives and unique identity. Together, our community strives to create and maintain working and learning environments that are inclusive, equitable and welcoming.

To request disability accommodation in the application process, contact the Disability Services Office at 206-543-6450 or [e-mail].

Applicants considered for this position will be required to disclose if they are the subject of any substantiated findings or current investigations related to sexual misconduct at their current employment and past employment. Disclosure is required under Washington state law.