Second Level Reviewer-Clinical Documentation Integrity

Dovel Technologies, Inc; United States; Hybrid; USD 89,000 - 148,000; Full time

Job summary

Dovel Technologies, Inc. is seeking a qualified CDI Second Level Reviewer to conduct comprehensive chart reviews to ensure accurate reflection of care and documentation in line with Official Coding Guidelines and CMS standards.

The role collaborates with CDI teams, physician advisors, coders, and quality staff to identify opportunities for education and improvement, performing audits, and ensuring coding and documentation support severity of illness and risk of mortality.

Qualifications

• Nursing BSN/ADN or medical degree or health-related bachelor’s/master’s.
• Experience with clinical documentation and CDI reviews.
• Knowledge of Official Coding Guidelines and CMS requirements.

Responsibilities

• Perform comprehensive secondary clinical reviews to verify accuracy of care and DRG assignments.
• Collaborate with CDI team, physicians, coders and quality staff to educate and improve documentation.
• Identify opportunities for improvement and ensure documentation supports severity of illness and mortality risk.
• Adhere to AHIMA/ACDIS guidelines and guidehouse processes for queries and documentation integrity.

Skills

Clinical documentation

Critical thinking

Encoder experience

DRG assignments

AHIMA/ACDIS guidelines

Education

BSN or ADN or MD

Health-related bachelor’s or master’s

CCDS/CDIP (Nice to have)

Tools

Encoder software

DRG validation tools

Job description

**What You Will Do:**Second level reviewer responsibilities include comprehensive, clinical chart reviews to ensure the most accurate reflection of the patient’s care and diagnosis following Official Coding Guidelines, Coding Clinics, and Client policies.The Clinical Documentation Integrity (CDI) Second Level Reviewer will collaborate closely with the CDI team, Physician Advisors, Providers, Clinicians, Coding Educator, Coding Quality Auditors, Case Managers and Quality Department 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. Applies the Association of Clinical Documentation Integrity Specialist (ACDIS) best practices for writing clinical documentation integrity clarifications (see *Achieving a Compliant Query)* and follows the CDI Code of Ethics. Collaborates with CDI Management/Educator to identify opportunities for education with CDI team, Coding, Providers and/or other ancillary staff to improve the overall quality and completeness of documentation.The second level review role is dynamic, requiring adaptation to various clinical and administrative needs. This flexibility is essential for effectively addressing the evolving challenges in clinical documentation, ensuring the accuracy and compliance of patient records. The incumbent will navigate multiple responsibilities with agility, participating in diverse projects and initiatives that enhance documentation quality and patient care standards.* Understands quality risk models and apply them during secondary reviews.* 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.* Demonstrates excellent verbal and written communication skills, crucial for effective interaction with healthcare professionals and the creation of compliant queries.* Acts as a liaison between the Coding Department and the Clinical Documentation Specialist to reconcile discrepancies in code and/or DRG assignment.* Exhibits adeptness in quickly learning and adapting to new technologies. Proficient in utilizing EHR systems, CDI software, and encoders to optimize workflow and boost productivity.* Apply the principles of clinical validation and ensure that queries are compliant with AHIMA guidelines.Duties:* 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.* Demonstrated ability to collaborate with the Quality Department on annual quality initiatives.* 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 by the client for potential missed opportunities to clarify documentation or clinically validate a diagnosis.* Consistently meet second level review productivity, quality, and turnaround expectations, including mailbox inquiries and mortality reviews, to support Guidehouse client metrics.* Acts as a liaison between the Coding Department and the Clinical Documentation Specialist to reconcile discrepancies in code and/or DRG assignment.* Collaborates with CDI educator/quality auditor when educational needs are identified from second level reviews* Document and track the results of secondary reviews, sharing information during formal and informal education sessions to all stakeholders (CDI, Leadership, Physicians), via by engaging in collaborative interactions with physicians and other clinicians to enhance understanding of CDI program goals.* Collaborative interaction with physicians and/or other clinicians to enhance understanding of the CDI program goals.* Perform impartial audits of front-line CDI documentation using Guidehouse criteria, provide professional feedback and mentorship, and escalate unresolved disagreements through appropriate leadership channels.* Participate in departmental and hospital committees, assigned task forces, and service line assignment meetings as requested.* Contribute to a positive and collaborative working environment.* Perform other duties as assigned.* Comply with HIPAA and code of conduct policies.**What You Will Need:*** 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**What Would Be Nice to Have:*** 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 systemThe annual salary range for this position is $89,000.00-$148,000.00. Compensation decisions depend on a wide range of factors, including but not limited to skill sets, experience and training, security clearances, licensure and certifications, and other business and organizational needs.