Second Level Reviewer-Clinical Documentation Integrity

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

About the role

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. Demonstrates excellent verbal and written communication skills, crucial for effective interaction with healthcare professionals and the creation of compliant queries. Exhibits