Clinical Documentation Integrity Specialist - Second Level Reviewer

Job Family:

CDI Specialist

Travel Required:

None

Clearance Required:

None

What You Will Do

Clinical Documentation Integrity (CDI) Second Level Reviewer responsibilities include comprehensive, clinical chart reviews to ensure the most accurate reflection of the patient’s care and diagnosis following Official Coding Guidelines, Coding Clinics, and UAB policies. The Clinical Documentation Integrity (CDI) Second Level Reviewer will collaborate closely with the CDI team, Physician Advisors, Providers, Clinicians, Coders, 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 current CMS or other regulatory standards. Applies the Association of Clinical Documentation Integrity Specialist (ACDIS) best practices for writing clinical documentation integrity 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 Clinical Documentation Integrity (CDI) Second Level Reviewer 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.

Responsibilities Include:

• 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.

• 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.

• Consistently meet second level review productivity, quality, and turnaround expectations, including mailbox inquiries and mortality reviews, to support Guidehouse 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 when educational needs are identified from second level reviews

• Communicate findings from secondary reviews to Clinical Documentation Specialists for follow-up and query initiation and education; and collaborate with CDI educator and quality auditors to identify and address educational needs.

• Document and track the results of secondary reviews, sharing information during formal and informal education sessions to all stakeholders (CDI, Leadership, Physicians), via 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; ensure the medical record can be coded accurately in order to accurately reflect patient severity of illness and risk of mortality.

• Perform impartial audits of front-line CDI documentation using Guidehouse criteria, provide professional feedback and mentorship, and escalate unresolved disagreements through appropriate leadership channels.

• Complete second level reviews of specific patient populations (per UAB guidance) to identify documentation improvement opportunities, accurate selection of principal and/or other diagnosis, procedures and present on admission status (when appropriate).

• Acts as a liaison between the Coding Department and the Clinical Documentation Specialist to reconcile discrepancies in code and/or DRG assignment.

• Seasoned technical individual contributor: works independently on large or complex projects and assignments, with minimal guidance

• Works to influence parties within and outside of the job function at an operational level regarding policies, practice