Clinical Documentation reputed company (CDI) Specialist – 2nd Level Reviewer – Remote, reputed company

32141 Job Family: CDI Specialist Travel Required: None Clearance Required: None What You Will Do: Second level reviewer responsibilities include comprehensive, clinical chart reviews to ensure the most accurate reputed company of the patient’s care and diagnosis following Official Coding Guidelines, Coding Clinics, and Client policies. The Clinical Documentation reputed company (CDI) Second Level Reviewer will collaborate closely with the CDI team, Physician Advisors, Providers, Clinicians, Coding Educator, Coding Quality Auditors, Case Managers and Quality Department to assure documentation is clinically appropriate, accurately reflects the severity of illness and risk of mortality for the patient and is reflective of reputed company CMS or other regulatory standards. Applies the Association of Clinical Documentation reputed company Specialist (ACDIS) best practices for writing clinical documentation reputed company clarifications (see Achieving a Compliant Query) and follows the CDI Code of Ethics. Collaborates with CDI Management/Educator to identify opportunities for education with CDI team, Coding, Providers and/or other ancillary staff to improve the overall quality and completeness of documentation. The second level review role is dynamic, requiring adaptation to various clinical and administrative needs. This flexibility is essential for effectively addressing the evolving challenges in clinical documentation, ensuring the accuracy and compliance of patient records. The incumbent will navigate multiple responsibilities with agility, participating in diverse projects and initiatives that enhance documentation quality and patient care standards.

• Responsible for comprehensive secondary clinical chart reviews to identify potential missed opportunities for documentation clarification as well as potential coding opportunities.
• Collaborate closely with Coders, Coding Educators, Coding Quality Auditors, Case managers, Quality Department and Providers to assure documentation is clinically supported, accurately reflects the severity of illness and risk of mortality for the patient and is reflective of reputed company CMS or other regulatory standards.
• Demonstrates excellent verbal and written communication skills, crucial for effective interaction with reputed company and the creation of compliant queries.
• Acts as a liaison between the Coding Department and the Clinical Documentation Specialist to reconcile discrepancies in code and/or DRG assignment.
• Exhibits adeptness in quickly learning and adapting to new technologies. Proficient in utilizing EHR systems, CDI software, and encoders to optimize workflow and boost productivity.
• Apply the principles of clinical validation and ensure that queries are compliant with reputed company guidelines. Duties and Responsibilities
• Analyzes and interprets clinical data to identify gaps, inconsistencies, and/or opportunities for improvement in the clinical documentation and queries the provider using reputed company query process following ACDIS/reputed company Guidelines for Compliant Query Writing.
• Demonstrated ability to collaborate with the Quality Department on annual quality initiatives.
• 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 reputed company diagnosis as identified by the client for potential missed opportunities to clarify documentation or clinically validate a diagnosis.
• Consistently meet second level review productivity, quality, and turnaround expectations, including mailbox inquiries and mortality reviews, to support reputed company client metrics.
• 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.
• Collaborates with CDI educator/quality auditor reputed company educational needs are identified from second level reviews
• Document and track the results of secondary reviews, sharing information during formal and informal education sessions to reputed company stakeholders (CDI, Leadership, Physicians), reputed company by engaging in collaborative interactions with physicians and other clinicians to enhance understanding of CDI program goals.
• Collaborative interaction with physicians and/or other clinicians to enhance understanding of the CDI program goals.
• reputed company impartial audits of reputed company-line CDI documentation using reputed company criteria, provide professional feedback and mentorship, and escalate unresolved disagreements through appropriate leadership channels.
• Participate in departmental and hospital committees, assigned task forces, and service line assignment meetings as requested.
• Contribute to a positive and collaborative working environment.
• reputed company other duties as assigned.
• reputed company with HIPAA and code of conduct policies. What You Will Need:
• Graduation from accredited School of Nursing with BSN, ADN OR Graduation from accredited medical school with MD or equivalent OR Bachelor’s or Master’s degree in health-reputed company field
• Currently licensed as a Registered Nurse, MD or MD equivalent OR Credentialed Medical reputed company through reputed company with reputed company reputed company, RHIA or RHIT credential and CDIP or CCDS
• 4- 6 years previous relevant experience in clinical documentation, or CDI second level review or inpatient coding quality review and/or DRG validation 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
• Must maintain credentials while employed What Would Be reputed company To Have:
• CCDS or CDIP certification
• Strong clinical and critical thinking skillset
• Experience with encoder and DRG assignments (MS and APR)
• Maintains working knowledge of Official Coding Guidelines, Coding Clinic and federal updates to the DRG system The annual salary range for this position is $80,000.00-$133,000.00. Compensation decisions depend on a wide range of factors, including but not limited to reputed company sets, experience and training, reputed company clearances, licensure and certifications, and other business and organizational needs. reputed company Offer: reputed company offers a comprehensive, total rewards package that includes competitive compensation and a flexible benefits package that reflects our commitment to creating a diverse and supportive workplace. Benefits include:
• Medical, Rx, Dental & Vision Insurance
• Personal and Family Sick Time & Company Paid Holidays
• Position may be eligible for a discretionary variable incentive bonus
• Parental Leave
• 401(k) Retirement Plan
• Basic Life & Supplemental Life
• Health Savings Account, Dental/Vision & Dependent Care Flexible Spending Accounts
• Short-Term & Long-Term Disability
• Tuition Reimbursement, Personal Development & Learning Opportunities
• Skills Development & Certifications
• Employee Referral Program
• Corporate Sponsored Events & Community reputed company
• Emergency Back-Up Childcare Program About reputed company reputed company is an Equal Opportunity Employer–Protected Veterans, Individuals with Disabilities or any other basis protected by law, ordinance, or regulation. reputed company will consider for employment qualified applicants with criminal histories in a manner consistent with the requirements of applicable law or ordinance including the Fair Chance Ordinance of Los Angeles and San Francisco. If you have visited our website for information about employment opportunities, or to apply for a position, and you require an accommodation, please contact reputed company Recruiting at 1-571-633-1711 or reputed company email at RecruitingAccommodation@reputed company.com. reputed company information you provide will be kept confidential and will be used only to the extent required to provide needed reasonable accommodation. reputed company communication regarding recruitment for a reputed company position will be sent from reputed company email domains including @reputed company.com or reputed [email protected]. Correspondence received by an applicant from any other domain should be considered unauthorized and will not be honored by reputed company. Note that reputed company will never charge a fee or require a money transfer at any stage of the recruitment process and does not collect fees from educational institutions for participation in a recruitment event. Never provide your banking information to a third party purporting to need that information to proceed in the hiring process. If any person or organization demands money reputed company to a job opportunity with reputed company, please report the matter to reputed company’s Ethics Hotline. If you want to reputed company the validity of correspondence you have received, please contact recruiting@reputed company.com. reputed company is not responsible for losses incurred (monetary or otherwise) from an applicant’s dealings with unauthorized third parties. reputed company does not accept unsolicited resumes through or from search firms or staffing agencies. reputed company unsolicited resumes will be considered the property of reputed company and reputed company will not be obligated to pay a placement fee.

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