Clinical Documentation Integrity - Second Level Reviewer

Position Overview

The Clinical Documentation Integrity (CDI) Second Level Reviewer performs high-level, complex, secondary case reviews to ensure accurate clinical documentation that reflects severity of illness, risk of mortality, and complexity of patient care. Working in collaboration with CDI & quality leadership, CDI specialists, coders, quality analysts, providers, and other healthcare team members, this role identifies documentation opportunities, facilitates queries, and supports regulatory compliance and quality initiatives.

Key Responsibilities

• Ensures accuracy, completeness, and quality of clinical information used for reporting physician and hospital outcomes.
• Performs high-level, complex, timely secondary case reviews to identify potential gaps and facilitate improved provider documentation.
• Verifies that clinical documentation accurately reflects the level of care rendered, severity of illness, and risk of mortality in compliance with regulatory requirements.
• Applies advanced knowledge of CMS star rating, Vizient, and US News risk-adjustment systems to identify improvement opportunities.
• Conducts quality reviews focused on CDI quality elements such as mortality, Hospital Acquired Conditions (HAC), and other safety metrics.
• Identifies trends and key areas for improvement in querying, coding, and documentation integrity.
• Utilizes proficiency with ICD-10-CM/PCS, APR DRG, and MS DRG to address coding and DRG assignment issues.
• Employs strong critical-thinking skills and sound judgment to recommend documentation improvements while ensuring compliance.
• Facilitates high-quality documentation by composing effective, clear, concise, and compliant queries per current practice briefs.
• Recommends refinements to principal or secondary diagnoses and/or procedures based on clinical data.
• Records review findings and data elements accurately into CDI software to support data integrity for reporting.
• Communicates and collaborates effectively with providers, HIM/coding, quality, CDI teams, and other stakeholders.
• Assists with concurrent and retrospective CDI case reviews, quality audits, and staff education as needed.
• Manages time and priorities independently while ensuring adherence to deadlines and departmental objectives.
• Participates in meetings, provides feedback, and identifies trends and opportunities for educational initiatives.
• Takes responsibility for professional development through workshops, conferences, and in-service trainings.
• Engages in departmental projects, task forces, and committees as required.
• Ensures strict adherence to HIPAA and Code of Conduct policies.

Required Qualifications

• Education: Four (4) year/bachelor’s degree required; BSN/BS/BA in a related field required; Graduate degree in Healthcare Administration, Informatics, Nursing, Leadership, Education or a related field is a plus.
• Certification and Licensing: Current RN or MD required; CCDS or CDIP certification required; Coding certification (CCS, CIC, or CPC) is preferred.
• Experience Required: At least three (3) years of recent inpatient clinical documentation improvement (CDI) experience required, including a minimum of one (1) year focused on quality reviews (mortality, PSI, HAC, etc.); proficiency with ICD-10-CM/PCS, APR DRG, MS DRG, CDI software, and Microsoft Office is required.

Preferred Qualifications

• Graduate degree in Healthcare Administration, Informatics, Nursing, Leadership, Education or a related field preferred.
• Coding certification (CCS, CIC, or CPC) preferred.
• At least three (3) years of direct patient care clinical experience in a hospital setting preferred.
• Knowledge of Vizient, Premier, US News and World Report, CMS star rating or similar risk-adjustment methodologies highly preferred.
• Experience with 3M 360 Encompass preferred.
• Prior experience in an academic medical center or large health system preferred.
• Excellent written and verbal communication skills with the ability to communicate concisely and effectively.

Benefits & Perks

• Benefits: Competitive salaries and a comprehensive benefits package including medical, dental, tuition remission and more.