Urgently Need Clinical Documentation Integrity (CDI) Specialist- 2nd Level Reviewer- Remote in Washington DC

Job title: Clinical Documentation Integrity (CDI) Specialist- 2nd Level Reviewer- Remote Company: Dovel Technologies Job description: Job Family: CDI Specialist Travel Required: None Clearance Required: None What You Will Do: The CDI Specialist- 2nd 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 as a CDI educator 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 Coders, Coding Educators, Coding Quality Auditors, Case managers, Quality Department 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.
• Work with CDI leadership to plan, develop, and implement clinical documentation education programs for CDI specialists and providers.
• Utilizes comprehensive knowledge of ICD-10-CM coding guidelines and clinical knowledge to educate coding and CDI staff on best practice principals.
• Work on efforts to improve provider clinical documentation and providing an accurate clinical picture of the patient including severity of illness, risk, and resource utilization.
• Conduct individual and large group educational sessions for all CDI Specialists and/or providers.
• Performs monthly CDI audits and reviewing for educational opportunities.
• Working closely with the CDI Specialists, identify areas of non-specific documentation and improve documentation templates in support of clinical treatment protocols.
• Communicates findings of secondary reviews to respective Clinical Documentation Specialist for follow-up and query initiation.
• Completes comprehensive, clinical secondary reviews of targeted patient populations to include cases with DRG and/or code discrepancies; mortality reviews to ensure documentation supports risk of mortality; hospital acquired conditions (HACs), patient safety indicators (PSIs) or other top priority diagnosis as identified by UAB for potential missed opportunities to clarify documentation or clinically validate a diagnosis.
• Acts as a liaison between the Coding Department and the Clinical Documentation Specialist to reconcile discrepancies in code and/or DRG assignment.
• Documents and tracks second level reviews and results. Shares this information with staff at monthly CDI team meeting.
• Collaborative interaction with physicians and/or other clinicians to enhance understanding of the CDI program goals; ensure the medical record can be coded accurately in order to accurately reflect patient severity of illness and risk of mortality.

What You Will Need:

• Graduation from accredited School of Nursing with BSN, ADN, OR Bachelor s Degree or Masters Degree in health related field OR graduation from accredited medical school with MD or DO
• Currently licensed or licensed by endorsement as a Registered Nurse, MD or MD equivalent OR credentialed medical coder with current CCS credential
• Minimum of three to five years as a Clinical Documentation Integrity Specialist required.
• Exhibits strong clinical, critical thinking skillset
• Experience providing education to CDI teams.
• Ability to perform monthly audits.
• Experienced Clinical Documentation Integrity Specialist (minimum 3-5 years) or CDI Second Level Reviewer with a strong understanding of disease processes, clinical indications and treatments; provider documentation requirements to 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 Coding Guidel

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