Clinical Documentation Improvement Second Level Reviewer
Company: CHRISTUS Health
Location: Grand Prairie
Posted on: January 19, 2023
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Job Description:
Description
Summary:
(CDI) Second Level Reviewer (SLR) is a professional CDI with a
strong clinical knowledge base and advanced understanding of DRG
documentation requirements who works under the supervision of the
CDI director. Responsibilities include secondary clinical chart
reviews, resolution of DRG discrepancies, and education to clinical
staff regarding opportunities for diagnosis clarification,
principal diagnosis accuracy and improvement of capture of
additional comorbid conditions. The second level reviewer will
conduct concurrent and retrospective medical record review on
defined patient populations to identify opportunities to improve
accuracy of documentation and collaborate with the coding
department to assure documentation is clinically appropriate,
accurately reflects the severity of illness for the patient, and is
reflective of current CMS standards.
Second level reviewer responsibilities include comprehensive
secondary clinical chart reviews to identify potential missed
opportunities for documentation clarification, act as a liaison
between coding and CDI to resolve DRG or other code discrepancies,
collaborate with CDI Director to educate CDI team based on
opportunities identified in second level reviews and work directly
with clinicians and providers to improve the overall quality and
completeness of documentation through the query process and/or
provider education. The Clinical Documentation Integrity Second
Level Reviewer will collaborate closely with Quality Auditors, Case
managers, Quality Department and Providers to assure documentation
is clinically appropriate, accurately reflects the severity of
illness and risk of mortality for the patient and is reflective of
current CMS or other regulatory standards.
Analyzes and interprets clinical data to identify gaps,
inconsistencies, and/or opportunities for improvement in the
clinical documentation and queries the provider using concurrent
query process following ACDIS/AHIMA Guidelines for Compliant Query
Writing.
Complete comprehensive, clinical secondary reviews of targeted
patient populations to include cases with DRG and/or code
discrepancies; mortality reviews to ensure documentation supports
risk of mortality; hospital acquired conditions (HACs), patient
safety indicators (PSIs) or other top priority diagnosis as
identified by UAB for potential missed opportunities to clarify
documentation or clinically validate a diagnosis.
Acts as a liaison between the Coding Department and the Clinical
Documentation Specialist to reconcile discrepancies in code and/or
DRG assignment
Communicates findings of secondary reviews to respective Clinical
Documentation Specialist for follow-up and query initiation.
Collaborates with CDI educator/quality auditor when educational
needs are identified from second level reviews.
Documents and tracks second level reviews and results. Shares this
information with staff at monthly CDI team meeting.
Collaborative interaction with physicians and/or other clinicians
to enhance understanding of the CDI program goals; ensure the
medical record can be coded accurately in order to accurately
reflect patient severity of illness and risk of mortality
Collaborates with other clinical disciplines (i.e. quality, case
management etc.) and members of the coding department to ensure
high quality clinical documentation and efficient, timely coding of
the medical record.
Participates in performance improvement activities related to the
operational processes for the Documentation Integrity Program as
well as related organizational/departmental goals.
Develops collaborative relationships and promotes team- work with
co-workers and other departments.
Subject matter expert for CDI Concurrent Review Teams.
Performs other duties as assigned.
Requirements:
Graduation from accredited School of Nursing; BSN or Bachelor's
degree in health-related field and/or
Graduation from accredited medical school; MD or DO preferred
Minimum of (3-5) years as a Clinical Documentation Integrity
Specialist required.
Exhibits strong clinical, critical thinking skillset
Experienced Clinical Documentation Integrity Specialist (minimum 5
years) or CDI Second Level Reviewer with a strong understanding of
disease processes, clinical indications and treatments; provider
documentation requirements to reflect severity of illness, risk of
mortality and support the diagnosis/procedures performed for
accurate clinical coding and billing according the rules of
Medicare, Medicaid, and commercial payors as well as a solid
understanding of hospital acquired conditions (HAC's) , patient
safety indicators (PSI's) and mortality models.
Experience with encoder and DRG assignments (MS and APR)
Maintains working knowledge of official knowledge of Official
Coding Guidelines, Coding Clinic and federal updates to the DRG
system
Excellent communication skills, with ability to listen and
understand client request and needs while employing tact and
effectiveness
Ability to conduct meaningful conversations and /or presentations
with providers in all situations
Currently licensed or licensed by endorsement as a Registered
Nurse, MD or MD equivalent.
CDIP or CCDS Certification required.
CCS preferred
Work Type:
Full Time
Keywords: CHRISTUS Health, Grand Prairie , Clinical Documentation Improvement Second Level Reviewer, Healthcare , Grand Prairie, Texas
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