Second Level Reviewer-Clinical Documentation Integrity

Guidehouse Inc.; United States; On-site; USD 75,000 - 110,000; Full time

Job summary

Guidehouse Inc. is seeking a CDI Second Level Reviewer to perform thorough clinical chart reviews ensuring documentation accurately reflects patient care and severity of illness in line with official guidelines.

The role requires collaboration with physicians, CDI educators, and quality staff to improve documentation quality and ensure regulatory alignment. Strong communication and proficiency with CDI tools are essential.

Qualifications

• Requires nursing or medical degree with licensure.
• Familiarity with Official Coding Guidelines and AHIMA/ACDIS.
• Strong written and verbal communication skills.

Responsibilities

• Perform comprehensive clinical chart reviews to ensure accurate reflection of care and diagnoses.
• Collaborate with CDI team, physicians, providers, and quality staff to ensure documentation accuracy and regulatory compliance.
• Conduct second level reviews of targeted patient populations for DRG/code discrepancies and mortality reviews.
• Meet productivity, quality, and turnaround targets for second level reviews and inquiries.
• Document and share results with stakeholders (CDI, Leadership, Physicians) in formal/informal sessions.
• Comply with HIPAA and code of conduct policies.

Skills

Clinical documentation

ACDIS guidelines

Healthcare communication

Cross-functional collaboration

Education

BSN or ADN

MD or equivalent

Health-related bachelor’s/master’s

Tools

EHR systems

CDI software

Encoders

Job description

Job Family : CDI Specialist Travel Required : None Clearance Required : None

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 escalation 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