Clinical Documentation Quality Reviewer / CDI Query Writer
About The Position
The Clinical Documentation Quality Reviewer supports Second Wave Delivery Systems’ mission to ensure accurate clinical documentation, appropriate reimbursement, and a true reflection of the quality of care delivered. The primary focus is reviewing quality measures, including Patient Safety Indicators (PSIs), CMS Core Measures, and mortality cases, to identify documentation and coding opportunities affecting quality outcomes, publicly reported data, and risk-adjusted performance. This is a team-based role. When quality review volume allows, the reviewer supports the CDI query team by drafting, issuing, and managing compliant physician queries that clarify documentation, resolve coding ambiguities, and improve DRG and SOI accuracy. The role collaborates with DRG Validation Auditors, Medical Directors, Query Writers, revenue cycle analysts, CDI professionals, inpatient coders, and quality teams.
Requirements
- Prior experience as a Clinical Documentation Improvement Specialist within a hospital setting.
- Bachelor’s degree or equivalent experience required.
- Clinical background or training as a Registered Nurse, Nurse Practitioner, Occupational Therapist, Physical Therapist, Physician Assistant, or Physician.
- Demonstrated experience working in an Electronic Medical Record (EMR) environment.
- Minimum of five years of recent hospital experience and/or verifiable documentation improvement expertise.
- Proficiency with 3M Encoder Systems.
- Working knowledge of AHRQ PSI methodology, present-on-admission (POA) rules, and risk-adjustment concepts, including SOI/ROM and expected versus observed mortality.
- Strong understanding of coding guidelines, DRG assignment, and clinical terminology.
- Excellent written communication skills for clear, compliant query development and review findings.
- Ability to interpret clinical indicators and apply coding principles accurately.
- Detail-oriented with strong organizational and follow-up skills.
- Proficient in EHR systems and query management tools.
- Flexibility to shift between quality review and query work based on team needs.
Nice To Haves
- Experience with quality measure review, including PSIs, mortality reviews, and/or CMS Core Measures.
- CCDS, CDIP, or similar credential.
Responsibilities
- Review inpatient records flagged for Patient Safety Indicators, including PSI-90 components, to validate whether events are clinically supported, present on admission, or excluded, and identify documentation or coding opportunities.
- Review mortality cases to ensure documentation accurately captures severity of illness, risk of mortality, comorbidities, and palliative or hospice status affecting expected mortality and risk adjustment.
- Review records for CMS Core Measures to identify documentation gaps and ensure measure-related documentation is complete and accurate.
- Recommend coding changes or physician queries when documentation does not support or fully explain a quality event.
- Track and report findings, trends, and outcomes from quality reviews to support client reporting and provider education.
- Develop and issue compliant physician queries based on clinical indicators, coding guidelines, and documentation gaps when supporting the CDI query team.
- Review medical records to identify clarification opportunities affecting DRG assignment, SOI/ROM, and reimbursement integrity.
- Track and follow up on outstanding queries to ensure timely response and resolution.
- Ensure queries and review findings adhere to AHIMA and ACDIS standards for compliance and neutrality.
- Collaborate with CDI professionals, inpatient coders, and quality teams to align documentation with coding and regulatory requirements.
- Maintain accurate records of review and query activity for audit and reporting purposes.
- Participate in provider education initiatives on documentation best practices and quality measure impact.
- Perform other duties as assigned.
Benefits
- Health insurance
- Vision insurance
- Dental insurance
- Life insurance
- Retirement plan
- Paid time off
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
