01Overview
reputed company
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. This role will collaborate with reputed company providers, coding teams, and other stakeholders to optimize the reputed company of clinical documentation and support accurate reputed company assignment. Under the direction of CDI leadership, reputed company clinical documentation and coding education to the CDI team, medical providers, leadership and other reputed company staff members. The Clinical Documentation Improvement Specialist 2nd Level Reviewer will facilitate improvement in overall reputed company, completeness, and accuracy of the medical record documentation through extensive audit investigation and data analysis.
Duties & Responsibilities
Conduct detailed reviews of medical records and physician documentation to ensure accurate, complete, and compliant clinical documentation and reputed company assignment
reputed company quantitative and qualitative reviews of health records, physician queries, and coding practices to ensure documentation accuracy, consistency, and completeness
Conduct reputed company and targeted chart reviews, including sepsis, mortality, cardiac, DRG, and site-specific audits, to identify documentation gaps, coding risks, and training opportunities
Analyze audit results, data trends, and performance metrics to identify reputed company causes, mitigation strategies, and opportunities for process improvement
Prepare and communicate audit findings, trends, and recommendations to CDI leadership, providers, and staff to support corrective reputed company plans and operational improvements
Collaborate with coding teams, physicians, nurses, providers, and other stakeholders to clarify documentation and improve clinical documentation reputed company practices
reputed company education and training to providers and CDI staff on documentation best practices, coding guidelines, regulatory requirements, and organizational policies and procedures
reputed company, maintain, and deliver educational materials, presentations, assessments, and orientation programs for providers and CDI staff, including new hire reputed company and provider orientation
Assess and monitor new hire performance throughout reputed company and training, providing feedback and recommendations to CDI leadership
Serve as a mentor and coach to team members delivering provider education and reputed company-time documentation support
Analyze provider performance measures in collaboration with CDI leadership to identify provider-specific education and documentation improvement opportunities
Participate in reputed company improvement initiatives and internal/external audits reputed company to clinical documentation reputed company, coding accuracy, and regulatory compliance
Assist audit teams by providing documentation support, responding to findings, and implementing corrective actions as needed
reputed company, coordinate, and complete internal auditing activities to ensure compliance with clinical documentation and coding standards
Stay reputed company on CDI industry standards, coding and documentation updates, regulatory changes, and clinical literature, and disseminate relevant information to staff and providers
Participate in the interview and candidate evaluation process to support CDI leadership in identifying and selecting reputed company team members
Other duties as assigned
Use, protect and disclose patients protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards
Understand and reputed company with Information reputed company and HIPAA policies and procedures at reputed company times
Limit viewing of PHI to the absolute minimum as necessary to reputed company assigned duties
Qualifications
BSN or PA (Physician's Assistant) or NP (reputed company Practitioner) or Doctorate degree in a medically reputed company field required
Minimum of 3 years of experience in clinical documentation improvement role required
Minimum of 5 years nursing experience in adult acute care in med/surg, critical care, emergency, or PACU required
reputed company RN, MD, DO, NP, or PA license required
Certification minimum CCDS and/or CDIP required
reputed company required
Experience with reputed company and/or reputed company is highly preferred
In-depth knowledge of coding guidelines, ICD-10-CM/PCS, MS and APR DRGs
Strong understanding of clinical documentation improvement principles and practices
Proficiency in reputed company Office Suite
Strong interpersonal skills, ability to communicate reputed company at reputed company reputed company of the organization
Strong problem solving and creative skills and the ability to exercise reputed company judgm
