CDI Specialist 2nd Level Reviewer & Educator- Remote

Duties & Responsibilities

• Conduct detailed reviews of medical records and physician documentation to ensure accurate, complete, and compliant clinical documentation and code assignment
• Perform quantitative and qualitative reviews of health records, physician queries, and coding practices to ensure documentation accuracy, consistency, and completeness
• Conduct ad hoc and targeted chart reviews, including sepsis, mortality, cardiac, DRG, and site-specific audits, to identify documentation gaps, coding risks, and training opportunities
• Analyze audit results, data trends, and performance metrics to identify root causes, mitigation strategies, and opportunities for process improvement
• Prepare and communicate audit findings, trends, and recommendations to CDI leadership, providers, and staff to support corrective action plans and operational improvements
• Collaborate with coding teams, physicians, nurses, providers, and other stakeholders to clarify documentation and improve clinical documentation integrity practices
• Provide education and training to providers and CDI staff on documentation best practices, coding guidelines, regulatory requirements, and organizational policies and procedures
• Develop, maintain, and deliver educational materials, presentations, assessments, and orientation programs for providers and CDI staff, including new hire onboarding and provider orientation
• Assess and monitor new hire performance throughout onboarding and training, providing feedback and recommendations to CDI leadership
• Serve as a mentor and coach to team members delivering provider education and real-time documentation support
• Assist audit teams by providing documentation support, responding to findings, and implementing corrective actions as needed
• Develop, coordinate, and complete internal auditing activities to ensure compliance with clinical documentation and coding standards
• Stay current on CDI industry standards, coding and documentation updates, regulatory changes, and clinical literature, and disseminate relevant information to staff and providers
• Participate in the interview and candidate evaluation process to support CDI leadership in identifying and selecting qualified team members

Qualifications

• BSN or PA (Physician's Assistant) or NP (Nurse Practitioner) or Doctorate degree in a medically related field required
• Minimum of 3 years of experience in clinical documentation improvement role required
• Minimum of 5 years nursing experience in adult acute care in med/surg, critical care, emergency, or PACU required
• Active RN, MD, DO, NP, or PA license required
• Certification minimum CCDS and/or CDIP required
• CCS preferred
• Experience with 3M and/or Epic is highly preferred
• In-depth knowledge of coding guidelines, ICD-10-CM/PCS, MS and APR DRG’s
• Strong understanding of clinical documentation improvement principles and practices
• Proficiency in Microsoft Office Suite
• Strong interpersonal skills, ability to communicate well at all levels of the organization
• Strong problem solving and creative skills and the ability to exercise sound judgment and make decisions based on accurate and timely analyses
• High level of integrity and dependability with a strong sense of urgency and results oriented
• Excellent written and verbal communication skills required