CDI Specialist 2nd Level Reviewer- Educator Focused (Remote)

Job Purpose

This position is an Educator position.

The Clinical Documentation Improvement Specialist 2nd Level Reviewer (Educator focused) is responsible for conducting in-depth reviews of clinical documentation to ensure compliance with coding guidelines, regulatory requirements, and overall accuracy.

They collaborate with healthcare providers, coding teams, and other stakeholders to optimize the quality of clinical documentation and support accurate code assignment.

Under the direction of CDI leadership, provide virtual, recorded and classroom clinical documentation and coding education to the CDI team, medical providers, leadership and other healthcare staff members.

You will facilitate improvement in overall quality, completeness, and accuracy of the medical record documentation through extensive audit investigation and data analysis.

You will identify performance / documentation improvement opportunities related to clinical documentation.

Duties and Responsibilities

• Conduct detailed reviews of medical records and physician documentation to ensure accurate and comprehensive clinical documentation and code assignment
• Performs Ad-hoc reviews in collaboration with the quality team, including sepsis, mortality, cardiac, and others
• Review Pepper reports and provide feedback, mitigation, trends, and identify educational opportunities for team and providers
• Performs a quantitative and qualitative review and analysis of health records and physician queries to ensure documentation is accurate, consistent, complete and assigned codes can be supported by documentation.

Conducts chart reviews based on DRGs and site-specific trends to identify gaps in documentation and training opportunities.

Provides audit findings to CDI Leadership to assist with development of action plans when improved opportunities are identified.

Plans and directs orientation for all new Clinical Documentation Specialists.

Assess new hires throughout onboarding and training process and communicate assessments to CDI leadership.

Performs internal audits for CDS performance improvement, as needed.

Collaborate with CDI Leadership to develop training for identified knowledge gaps and / or at risk DRGs.

Stays current on all CDI related literature and current pathophysiology.

Respond to provider requests for CDI services.

In collaboration with CDI Manager, analyzes provider performance measures and assists in identification of provider specific education needs related to CDI process and clinical documentation.

Qualifications

CCS required.

Working Conditions

Perform light lifting (up to 15 pounds).

Subject to frequent interruptions.

Minimal occupational exposure to infectious diseases, blood borne pathogens, hazardous chemicals, noxious odors, latex, or musculoskeletal injuries.

Operate Office machines properly and in accordance with Hospital safety standards.

Ability to work in accordance with Hospital Safety Standards.

Med-Metrix will not discriminate against any employee or applicant for employment because of race, color, religion, sex (including pregnancy, gender identity, and sexual orientation), parental status, national origin, age, disability, genetic information (including family medical history), political affiliation, military service, veteran status, other non-merit based factors, or any other characteristic protected by federal, state or local law.