[Hiring] Clinical Documentation Coordinator / Second Level Reviewer @Bronson Healthcare

Role Description

The Clinical Documentation Coordinator / Second Level Reviewer (Remote) 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 manager. Responsibilities include:

• Conducting secondary clinical chart reviews.
• Resolving DRG discrepancies.
• Educating clinical staff regarding opportunities for diagnosis clarification, principal diagnosis accuracy, and improvement of capture of additional comorbid conditions.
• Conducting concurrent and retrospective medical record reviews on defined patient populations.
• Collaborating with the coding department to assure documentation is clinically appropriate and accurately reflects the severity of illness for the patient.
• Ensuring compliance with current CMS standards.

Qualifications

• Bachelor’s degree required.
• Graduation from accredited School of Nursing; BSN or bachelor’s degree in health-related field preferred.
• Minimum of (3-5) years as a Clinical Documentation Integrity Specialist required.
• Exhibits strong clinical, critical thinking skillset.
• Experienced Clinical Documentation Integrity Specialist or CDI Second Level Reviewer with a strong understanding of disease processes, clinical indications, and treatments.
• 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 Coding Guidelines, Coding Clinic, and federal updates to the DRG system.
• Currently licensed or licensed by endorsement as a Registered Nurse, MD, or MD equivalent.
• CDIP or CCDS Certification required or obtained within six months.

Requirements

• 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 manager to educate CDI team based on opportunities identified in second level reviews.
• Work directly with clinicians and providers to improve the overall quality and completeness of documentation.
• Analyze and interpret clinical data to identify gaps, inconsistencies, and/or opportunities for improvement in the clinical documentation.
• Complete comprehensive, clinical secondary reviews of targeted patient populations.
• Communicate findings of secondary reviews to respective Clinical Documentation Specialist for follow-up and query initiation.
• Collaborative interaction with physicians and/or other clinicians to enhance understanding of the CDI program goals.
• Collaborate with other clinical disciplines and members of the coding department to ensure high quality clinical documentation.

Company Description