Clinical Documentation Integrity (CDI) Specialist - 2nd Level Reviewer

Guidehouse • San Antonio, TX

111d • $80,000 - $133,000

About The Position

The Clinical Documentation Integrity (CDI) Second Level Reviewer is responsible for comprehensive clinical chart reviews to ensure accurate reflection of patient care and diagnosis according to Official Coding Guidelines, Coding Clinics, and Client policies. This role involves collaboration with various healthcare professionals to assure documentation is clinically appropriate and meets regulatory standards. The position requires flexibility to adapt to clinical and administrative needs, and the incumbent will participate in projects that enhance documentation quality and patient care standards. Responsibilities include analyzing clinical data, conducting secondary reviews, and communicating findings to improve documentation practices.

Requirements

• Graduation from accredited School of Nursing with BSN, ADN or equivalent medical degree.
• Currently licensed as a Registered Nurse, MD or equivalent, or Credentialed Medical Coder through AHIMA.
• 4+ years of relevant experience in clinical documentation or inpatient coding quality review.
• Strong understanding of disease processes, clinical indications, and documentation requirements.
• Must maintain credentials while employed.

Nice To Haves

• CCDS or CDIP certification.
• Strong clinical and critical thinking skills.
• Experience with encoder and DRG assignments.
• Knowledge of Official Coding Guidelines and federal updates.

Responsibilities

• Conduct comprehensive clinical chart reviews to ensure accurate documentation.
• Collaborate with CDI team, Physician Advisors, Providers, and other healthcare professionals.
• Apply ACDIS best practices for writing clinical documentation integrity clarifications.
• Identify opportunities for education with CDI team and other staff.
• Analyze clinical data to identify gaps and opportunities for improvement.
• Complete secondary reviews of targeted patient populations.
• Meet productivity, quality, and turnaround expectations for second level reviews.
• Act as a liaison between the Coding Department and Clinical Documentation Specialist.
• Document and track results of secondary reviews and share findings.
• Participate in departmental committees and task forces.

Benefits

• Medical, Rx, Dental & Vision Insurance.
• Personal and Family Sick Time & Company Paid Holidays.
• Discretionary variable incentive bonus eligibility.
• Parental Leave.
• 401(k) Retirement Plan.
• Basic Life & Supplemental Life Insurance.
• Health Savings Account and Flexible Spending Accounts.
• Short-Term & Long-Term Disability.
• Tuition Reimbursement and Personal Development Opportunities.
• Employee Referral Program.
• Corporate Sponsored Events & Community Outreach.
• Emergency Back-Up Childcare Program.

What This Job Offers

• Education Level: Bachelor's degree
• Number of Employees: 5,001-10,000 employees