Job Purpose
The Clinical Documentation Improvement Specialist 2nd Level Reviewer is responsible for conducting in-depth reviews of clinical documentation to ensure compliance with coding guidelines, regulatory requirements, and overall accuracy. This role will collaborate with healthcare providers, coding teams, and other stakeholders to optimize the quality of clinical documentation and support accurate code assignment. Under the direction of CDI leadership, provide clinical documentation and coding education to the CDI team, medical providers, leadership and other healthcare staff members. The Clinical Documentation Improvement Specialist 2nd Level Reviewer will facilitate improvement in overall quality, completeness, and accuracy of the medical record documentation through extensive audit investigation and data analysis.
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
- Analyze provider performance measures in collaboration with CDI leadership to identify provider-specific education and documentation improvement opportunities
- Participate in quality improvement initiatives and internal/external audits related to clinical documentation integrity, coding accuracy, and regulatory compliance
- 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
- Other duties as assigned
- Use, protect and disclose patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards
- Understand and comply with Information Security and HIPAA policies and procedures at all times
- Limit viewing of PHI to the absolute minimum as necessary to perform assigned duties
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 required
- 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
Working Conditions
- Ability to work outside of normal business hours as needed
- Must possess a smart-phone or electronic device capable of downloading applications, for multifactor authentication and security purposes
- Physical Demands: While performing the duties of this job, the employee is occasionally required to move around the work area; Sit; perform manual tasks; operate tools and other office equipment such as computer, computer peripherals and telephones; extend arms; kneel; talk and hear
- Mental Demands: The employee must be able to follow directions, collaborate with others, and handle stress
- Work Environment: The noise level in the work environment is usually minimal
Med-Metrix will not discriminate against any employee or applicant for employment because of race, color, religion, sex (including pregnancy, gender identity, and sexual orientation), parental status, national origin, age, disability, genetic information (including family medical history), political affiliation, military service, veteran status, other non-merit based factors, or any other characteristic protected by federal, state or local law.
Work Location: Remote
