Work Shift:

Day (United States of America)

Capital Health is the region's leader in providing progressive, quality patient care with significant investments in our exceptional physicians, nurses and staff, as well as advance technology. Capital Health is a five-time Magnet-Recognized health system for nursing excellence and is comprised of 2 hospitals. Capital Health Medical Group is made up of more than 250 physicians and other providers who offer primary and specialty care, as well as hospital-based services, to patients throughout the region.

Position Overview:

Clinical Documentation Second Level Reviewer

Job Description

POSITION SUMMARY

A clinical concurrent reviewer applies clinical and coding knowledge to concurrently evaluate the clinical indicators, diagnoses and treatment plan for assigned inpatients and identifies potential gaps in physician documentation.

The CDI second level reviewer (CDI SLR) is an advanced concurrent reviewer who uses his/her extensive Clinical Documentation Improvement (CDI) experience to perform a variety of second level reviews.The CDI SLR will conduct reviews post-discharge prior to final billing of target case populations, place queries if documentation opportunities are identified, and collaborate with the coding team on coding opportunities.The CDI SLR will also respond to concurrent review requests from CDSs and seek to improve process flow and SLR criteria when appropriate.Drawing on his/her advanced CDI knowledge, the CDI SLR will regularly analyze data and reports to identify trends and areas of opportunity and provide education to CDSs based on this analysis.

ROLES AND RESPONSIBILITIES

Performs post-discharge, final coded, pre-bill reviews of targeted records identified for secondlevel review for opportunity to accurately capture patient acuity, severity of illness, risk of mortality, and DRG assignment in compliance with industry rules and regulationsIf a documentation opportunity is identified, place physician query and follow up for response to ensure completeness and accuracy of the medical record oIf coding opportunity is identified, coordinate with coder and/or Coding Manager to review and address opportunity, as applicableResponds to CDS requests for concurrent chart reviewsMaintains a summary of opportunities identified through second-level review for feedback and education with the CDS team o Coordinate with other Second Level Reviewers and CDI Managers to compile trends and areas of opportunity and conduct education with the CDS team based on the findingsPeriodically review the criteria established for cases triggering a second-level review and recommend updates or modifications to the criteria to assist in identifying areas of opportunity

QUALIFICATIONS FOR CLINICAL DOCUMENTATION SECOND LEVEL REVIEWER

RN, preferably BSN with acute care experiencePrefer certification as CCDS or CDIPThree years of experience in clinical documentation improvement in an acute care settingAbility to work independently as well as in a team environmentStrong critical thinking skills and the ability to review the medical record to identify information not yet documented but supported by clinical indicators or clinical cluesExcellent communication and presentation skills

Offers are contingent upon successful completion of our onboarding process and pre-employment physical.  Capital Health will require all applicants (including contractors, travelers and consultants) to have an annual flu vaccine prior to start date, with the exception of individuals with medical and religious exemptions.

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