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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.

Requirements:

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.

Responsibilities:

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 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 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

Communicates findings of secondary reviews to respective Clinical Documentation Specialist for follow-up and query initiation.

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

Collaborate with other clinical disciplines (i.e. quality, case management etc.) and members of the coding department to ensure high quality clinical documentation and efficient, timely coding of the medical record.

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