Second Level Reviewer – Clinical Documentation Integrity

This is a fully remote position, open to applicants in United States.

📋 Description

• Conduct thorough reviews of clinical charts to ensure they accurately represent patient care and diagnoses.

• Execute secondary evaluations of specific patient groups, addressing DRG/code discrepancies, mortality assessments, HACs, PSIs, and key diagnoses.

• Analyze clinical data to pinpoint documentation deficiencies, inconsistencies, and areas for improvement.

• Engage with providers through the concurrent query process, adhering to ACDIS/AHIMA compliant query-writing standards.

• Implement clinical validation principles and quality risk models during secondary evaluations.

• Collaborate with CDI team members, Physician Advisors, providers, clinicians, coding educators, coding quality auditors, case managers, and the Quality Department.

• Reconcile coding and/or DRG assignment discrepancies between Coding and Clinical Documentation Specialists.

• Achieve productivity, quality, and turnaround expectations for second-level reviews, including addressing mailbox inquiries and mortality assessments.

• Work with CDI educators and quality auditors to determine educational requirements.

• Document and monitor secondary review outcomes and present findings in educational sessions.

• Conduct unbiased audits of frontline CDI documentation, offering feedback and guidance while escalating unresolved conflicts.

• Participate in departmental and hospital committees, task forces, and service line meetings.

• Foster a positive and collaborative work environment.

• Perform other related duties as assigned.

• Adhere to HIPAA regulations and code of conduct policies.

⛳️ Requirements

• Requires a University Degree and a minimum of 4-6 years of relevant experience; relevant experience may be considered in lieu of formal education or an advanced degree.

• Must be currently licensed as a Registered Nurse, MD, or equivalent OR credentialed as a medical coder through AHIMA with current CCS, RHIA, or RHIT credentials and CDIP or CCDS certification.

• 4-6 years of previous relevant experience in clinical documentation, CDI second-level review, inpatient coding quality review, and/or DRG validation.

• Strong knowledge of disease processes, clinical indications, and treatment protocols.

• Familiarity with provider documentation requirements for severity of illness, risk of mortality, and diagnosis/procedure support for accurate clinical coding and billing.

• Understanding of Medicare, Medicaid, and commercial payer regulations.

• Knowledge of hospital-acquired conditions (HACs), patient safety indicators (PSIs), and mortality models.

• Must maintain credentials throughout employment.

• Strong clinical and critical thinking abilities.

• Experience with encoder and DRG assignments (MS and APR).

• Working knowledge of Official Coding Guidelines, Coding Clinic, and federal updates to the DRG system.

• Excellent verbal and written communication skills.

• Proficiency in EHR systems, CDI software, and encoders.

• Familiarity with ACDIS and AHIMA compliant query guidelines.

• Ability to quickly learn and adapt to new technologies.

• Must comply with HIPAA regulations and code of conduct policies.

🏝️ Benefits

• Medical, Rx, Dental & Vision Insurance.

• Personal and Family Sick Time & Company Paid Holidays.

• Position may qualify for a discretionary variable incentive bonus.

• Parental Leave.

• 401(k) Retirement Plan.

• Basic Life & Supplemental Life Insurance.

• Health Savings Account, Dental/Vision & Dependent Care Flexible Spending Accounts.

• Short-Term & Long-Term Disability Insurance.

• Tuition Reimbursement, Personal Development & Learning Opportunities.

• Skills Development & Certifications.

• Employee Referral Program.

• Corporate Sponsored Events & Community Outreach.

• Emergency Back-Up Childcare Program.

• Flexible benefits package.

• Flexible work arrangements (remote).