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Short DescriptionThe Clinical Documentation Integrity (CDI) Second Level Reviewer performs high-level, complex, secondary case reviews to facilitate and obtain appropriate provider documentation for clinical conditions or procedures to reflect severity of illness, expected risk of mortality, accuracy of patient outcomes, and complexity of patient care. Serves as key resource for CDI/Coding/Quality. The CDI Second Level Reviewer works in collaboration with CDI & quality leadership, CDI specialists, coders, quality analysts, providers, and other members of the healthcare team to ensure accurate, high-quality clinical documentation to support CUH initiatives.
Performs high-level, complex, timely secondary case reviews concurrently and retrospectively to identify potential gaps or opportunities to facilitate improved provider documentation.
Recognizes opportunities for documentation improvement using strong critical-thinking skills and sound judgment in decision making, keeping integrity and compliance at the forefront of considerations in addition to outcomes, reimbursement, and regulatory requirements.
Facilitates high-quality documentation by utilizing queries that are effective, clear, concise, and compliant in accordance with latest AHIMA/ACDIS Query Practice Brief. Makes recommendation of possible refinement of principal diagnosis, secondary diagnoses, and/or procedures based on clinical data to facilitate appropriate DRG assignment.
Records review findings and other data elements accurately into CDI Software and other data mechanisms to support data integrity for reporting.
Effectively and appropriately communicates and collaborates with providers, HIM/coding, quality, CDI, and other members of the healthcare team. Demonstrates proficiency with ICD-10-CM/PCS, APR DRG, and MS DRG by providing information regarding clinical documentation opportunities, coding and DRG issues, as well as performance improvement methodologies.
Identify trends and key areas for improvement in querying, coding, and documentation integrity. Provides informal and formal education to individuals and on a group level.
Experience Required3-5 years recent work as Clinical Documentation Improvement Specialist required. Preferably Level 1 Trauma AMC (Academic Medical Center) or large health system. 3-5 years direct clinical care (nursing) in an acute hospital.
Education Requirements4 years/bachelor’s degree Required: Nursing
License/Certification RequirementsRegistered Nurse in any state
Certified Coding Specialist (CCS)
Clinical Documentation Improvement Practitioner (CDIP) OR Certified Clinical Documentation Improvement Specialist (CCDS
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