CDI Second Level Reviewer - Clinical Documentation Integrity | Remote WFH

Remote, USA Full-time Posted 2025-02-21

Job Overview

We are in search of a skilled Clinical Documentation Integrity (CDI) Second Level Reviewer to utilize your clinical and coding acumen in evaluating patient diagnoses and treatment plans for inpatients. In this pivotal role, you will focus on identifying documentation discrepancies and ensuring the precision of Clinical Documentation Integrity (CDI) capture...

As a CDI SLR, your responsibilities will include conducting post-discharge reviews prior to final billing, targeting specific cases for evaluation. You will work closely with the CDI team and coding professionals to discover opportunities for enhancing documentation and coding accuracy. Leveraging your extensive CDI expertise, you will regularly analyze data to discern patterns and provide constructive feedback that fosters the professional growth and development of Clinical Documentation Integrity Specialists. Your contributions will also be vital in refining processes and co-creating educational content in collaboration with management and CDI educators.

Key Responsibilities
? Conduct post-discharge, pre-billing reviews of selected patient records to ensure accurate representation of patient acuity, severity of illness, risk of mortality, and Diagnosis-Related Group (DRG) assignment in accordance with industry regulations.
? Initiate and follow up on physician queries to ensure that medical records are complete and accurate.
? Collaborate with coders and coding managers to address identified coding opportunities during reviews.
? Provide insightful feedback to the CDI team to uphold credible, effective, and compliant query practices.
? Partner with the Clinical Documentation Integrity Specialist educator to identify trends and formulate training and educational strategies.
? Respond to requests from Clinical Documentation Integrity Specialists for concurrent chart reviews.
? Track and document opportunities identified during second-level reviews for team feedback and educational purposes.
? Promote collaboration and build strong working relationships with physicians and healthcare professionals to advance program goals and enhance documentation standards.
? Assist in reviewing and refining criteria for cases necessitating second-level reviews and recommend updates to optimize the identification of documentation opportunities.

Required Skills
? Proficiency in Epic and 3M-360 software.
? Strong clinical documentation and coding expertise.
? Excellent analytical and problem-solving skills.
? Ability to work collaboratively with a diverse group of healthcare professionals.
? Exceptional communication skills for delivering effective feedback.

Qualifications
? A minimum of 5 years of relevant work experience.
? Completion of Nursing Specialty Training Program (Required).
? Bachelor's Degree in Nursing (Preferred).
? One of the following certifications is required:
? Certified Coding Specialist (AHIMA)
? Certified Clinical Documentation Specialist

Company Culture and Values

We Are Dedicated To Providing Exceptional Care For Our Patients, Members, And Communities. Our Core Values Are Evident In All We Do
? Kindness: Treating everyone with compassion and respect.
? Excellence: Striving for the highest standards in all endeavors.
? Learning: Sharing knowledge to prepare future caregivers.
? Innovation: Pursuing new and improved methods of patient care.
? Safety: Ensuring a safe environment for all.

Career Growth Opportunities

At our organization, we prioritize the professional development of our team members. From day one, we provide healthcare benefits for both full-time and part-time positions, including vision, dental, and domestic partner coverage. Our commitment to fostering a collaborative, inclusive, and supportive environment encourages teamwork at every level, ensuring that our staff can advance their skills and careers while contributing to our mission.

Employment Type: Full-Time

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