CDI Specialist 2nd Level Reviewer- Remote

Med-Metrix•Parsippany-Troy Hills, NJ

22h•Remote

About The Position

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 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 clinical documentation and coding education to the CDI team, medical providers, leadership and other healthcare staff members. The Clinical Documentation Improvement Specialist 2nd Level Reviewer will facilitate improvement in overall quality, completeness, and accuracy of the medical record documentation through extensive audit investigation and data analysis.

Requirements

BSN or PA (Physician's Assistant) or NP (Nurse Practitioner) or Doctorate degree in a medically related 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
Active RN, MD, DO, NP, or PA license required
Certification minimum CCDS and/or CDIP required
CCS required
In-depth knowledge of coding guidelines, ICD-10-CM/PCS, MS and APR DRG’s
Strong understanding of clinical documentation improvement principles and practices
Proficiency in Microsoft Office Suite
Strong interpersonal skills, ability to communicate well at all levels of the organization
Strong problem solving and creative skills and the ability to exercise sound judgment and make decisions based on accurate and timely analyses
High level of integrity and dependability with a strong sense of urgency and results oriented
Excellent written and verbal communication skills required

Nice To Haves

Experience with 3M and/or Epic is highly preferred

Responsibilities

Conduct detailed reviews of medical records and physician documentation to ensure accurate, complete, and compliant clinical documentation and code assignment
Perform quantitative and qualitative reviews of health records, physician queries, and coding practices to ensure documentation accuracy, consistency, and completeness
Conduct ad hoc 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 root 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 action plans and operational improvements
Collaborate with coding teams, physicians, nurses, providers, and other stakeholders to clarify documentation and improve clinical documentation integrity practices
Provide education and training to providers and CDI staff on documentation best practices, coding guidelines, regulatory requirements, and organizational policies and procedures
Develop, maintain, and deliver educational materials, presentations, assessments, and orientation programs for providers and CDI staff, including new hire onboarding and provider orientation
Assess and monitor new hire performance throughout onboarding and training, providing feedback and recommendations to CDI leadership
Serve as a mentor and coach to team members delivering provider education and real-time documentation support
Analyze provider performance measures in collaboration with CDI leadership to identify provider-specific education and documentation improvement opportunities
Participate in quality improvement initiatives and internal/external audits related to clinical documentation integrity, coding accuracy, and regulatory compliance
Assist audit teams by providing documentation support, responding to findings, and implementing corrective actions as needed
Develop, coordinate, and complete internal auditing activities to ensure compliance with clinical documentation and coding standards
Stay current 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 qualified team members
Use, protect and disclose patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards
Understand and comply with Information Security and HIPAA policies and procedures at all times
Limit viewing of PHI to the absolute minimum as necessary to perform assigned duties