Clinical Documentation Improvement Specialist 2nd Level Reviewer

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. They 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 virtual, recorded and classroom clinical documentation and coding education to the CDI team, medical providers, leadership and other healthcare staff members. You will facilitate improvement in overall quality, completeness, and accuracy of the medical record documentation through extensive audit investigation and data analysis. You will identify performance/documentation improvement opportunities related to clinical documentation.

Duties and Responsibilities

• Conduct detailed reviews of medical records and physician documentation to ensure accurate and comprehensive clinical documentation and code assignment
• Performs Ad-hoc reviews in collaboration with the quality team, including sepsis, mortality, cardiac, and others
• Review Pepper reports and provide feedback, mitigation, trends, and identify educational opportunities for team and providers
• Performs a quantitative and qualitative review and analysis of health records and physician queries to ensure documentation is accurate, consistent, complete and assigned codes can be supported by documentation. Conducts chart reviews based on DRGs and site-specific trends to identify gaps in documentation and training opportunities.
• Utilizes analysis of a variety of data sets and audits to assist in identifying gaps, root causes and solutions for CDSs and physician leadership. Provides audit findings to CDI Leadership to assist with development of action plans when improved opportunities are identified.
• Communicate and collaborate with coding teams, healthcare providers, physicians, nurses, and other stakeholders to clarify and improve documentation
• Participate in the interview process and evaluation of CDS candidates, assisting CDI Leadership in identifying the best candidates for hire. Plans and directs orientation for all new Clinical Documentation Specialists. Assess new hires throughout onboarding and training process and communicate assessments to CDI leadership.
• Provide education and training to healthcare providers on documentation best practices, coding guidelines, and regulatory requirements
• Stay updated on coding and documentation changes and disseminate relevant information to the team.
• Implement and maintain formal and informal educational materials, presentations, and assessments to support physician documentation compliance
• Educate CDI team to meet and maintain organizational goals and objectives, regulatory compliance, policy and procedures and personnel management. Performs internal audits for CDS performance improvement, as needed. Collaborate with CDI Leadership to develop training for identified knowledge gaps and/or at risk DRGs. Stays current on all CDI related literature and current pathophysiology.
• Develop and present provider education to keep them current in documentation principles and concepts relative to their areas of practice (including new provider orientations). Respond to provider requests for CDI services.
• Serve as mentor/coach for CDSs who will also be delivering provider education and real time documentation support
• In collaboration with CDI Manager, analyzes provider performance measures and assists in identification of provider specific education needs related to CDI process and clinical documentation
• Participate in quality improvement initiatives related to clinical documentation and coding accuracy
• Identify trends and patterns in documentation deficiencies and work towards implementing corrective actions
• Assist in internal and external audits by providing documentation and explanations related to coding and documentation practices
• Collaborate with audit teams to address findings and implement corrective actions
• Develops, coordinates and completes internal auditing activities to ensure compliance with documentation and coding practices. In collaboration with CDI Manager, analyzes provider performance measures and assists in identification of provider specific education needs related to CDI process and clinical documentation.
• Use, protect and disclose patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards
• Limit viewing of PHI to the absolute minimum as necessary to perform assigned duties
• 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 is highly preferred
• Minimum of 3 years of experience in clinical documentation improvement role
• Certification minimum CCDS and/or CDIP. CCS highly preferred
• Experience with 3M, Epic, and/or Nuance CDEOne 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
• Excellent communication and interpersonal skills

Working Conditions

• Ability to work outside of normal business hours as needed.
• 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. Perform light lifting (up to 15 pounds).
• Mental Demands: The employee must be able to follow directions, collaborate with others, and handle stress.
• Work Environment: Works in a well-lighted/ventilated office setting. Subject to frequent interruptions. Minimal occupational exposure to infectious diseases, blood borne pathogens, hazardous chemicals, noxious odors, latex, or musculoskeletal injuries. Operate Office machines properly and in accordance with Hospital safety standards. Ability to work in accordance with Hospital Safety Standards.

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.