Clinical Documentation Integrity (CDI) Specialist- 2nd Level Reviewer- Remote

Job Family:

Travel Required:

Clearance Required:

What You Will Do:

The CDI Specialist- 2nd Level Reviewer responsibilities include comprehensive secondary clinical chart reviews to identify potential missed opportunities for documentation clarification, act as a liaison between coding and CDI to resolve DRG or other code discrepancies, collaborate with CDI educator to educate CDI team based on opportunities identified in second level reviews and work directly with clinicians and providers to improve the overall quality and completeness of documentation through the query process and/or provider education. The Clinical Documentation Integrity Second Level Reviewer will 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. This position is 100% remote.

• 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.

• 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 UAB for potential missed opportunities to clarify documentation or clinically validate a diagnosis.

• Acts as a liaison between the Coding Department and the Clinical Documentation Specialist to reconcile discrepancies in code and/or DRG assignment

• Communicates findings of secondary reviews to respective Clinical Documentation Specialist for follow-up and query initiation.

• Collaborates with CDI educator/quality auditor when educational needs are identified from second level reviews

• Documents and tracks second level reviews and results. Shares this information with staff at monthly CDI team meeting.

• Collaborative interaction with physicians and/or other clinicians to enhance understanding of the CDI program goals; ensure the medical record can be coded accurately in order to accurately reflect patient severity of illness and risk of mortality

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 or licensed by endorsement as a Registered Nurse, MD or MD equivalent OR Credentialed Medical Coder through AHIMA with current CCS, RHIA or RHIT …