Clinical Documentation Coordinator​/Second Level Reviewer; Remote) ‑Time | per

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Portage-2825 Airview Blvd.

- Office Building

Clinical Documentation Coordinator / Second Level Reviewer (Remote) Full-Time | 80 Hours per Pay Period

CDI Second Level Reviewer (SLR) is a professional CDI with a strong clinical knowledge base and advanced understanding of DRG documentation requirements who works under the supervision of the CDI manager. Responsibilities include secondary clinical chart reviews, resolution of DRG discrepancies, and education to clinical staff regarding opportunities for diagnosis clarification, principal diagnosis accuracy and improvement of capture of additional comorbid conditions.

The second level reviewer will conduct concurrent and retrospective medical record reviews on defined patient populations to identify opportunities to improve accuracy of documentation and collaborate with the coding department to assure documentation is clinically appropriate, accurately reflects the severity of illness for the patient, and is reflective of current CMS standards.

• Education/Skills
  • Bachelor’s degree required
  • Graduation from accredited School of Nursing; BSN or bachelor’s degree in health-related field preferred
• Experience
  • Minimum of (3-5) years as a Clinical Documentation Integrity Specialist required.
  • Exhibits strong clinical, critical thinking skillset
  • Experienced Clinical Documentation Integrity Specialist or CDI Second Level Reviewer with a strong understanding of disease processes, clinical indications and treatments; provider documentation requirements to reflect severity of illness, risk of mortality and support the diagnosis/procedures performed for accurate clinical coding and billing according the rules of Medicare, Medicaid, and commercial payors as well as a solid understanding of hospital acquired conditions (HAC's), patient safety indicators (PSI's) and mortality models.
  • Experience with encoder and DRG assignments (MS and APR)
  • Maintains working knowledge of official knowledge of Official Coding Guidelines, Coding Clinic and federal updates to the DRG system
• Licenses, Registrations, or Certifications
  • Currently licensed or licensed by endorsement as a Registered Nurse, MD or MD equivalent.
  • CDIP or CCDS Certification required or obtained within six months.

• Second 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 manager 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 Compliance, Revenue Cycle Leaders, 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.
• 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.
• Complete comprehensive, clinical secondary reviews of targeted…