Position Summary
The CDI Specialist – Second Level Reviewer is responsible for performing advanced secondary reviews of clinical documentation, coding opportunities, and provider queries to ensure documentation accuracy, compliance, and appropriate reimbursement. This role serves as a quality and escalation resource, supporting accurate capture of severity of illness, risk of mortality, and overall clinical integrity.
Key Responsibilities
- Perform second-level reviews of inpatient medical records for documentation accuracy, coding opportunities, and query appropriateness
- Validate clinical indicators and supporting documentation for diagnoses, procedures, severity of illness, and risk adjustment opportunities
- Review and revise provider queries to ensure compliance with AHIMA, ACDIS, ICD-10, and AHA Coding Clinic guidelines
- Collaborate with CDI specialists, coding teams, physicians, and leadership to resolve complex documentation and coding issues
- Identify missed opportunities and provide feedback, education, and guidance to CDI staff regarding query formulation and documentation improvement strategies
- Escalate complex or high-risk cases as appropriate while ensuring documentation accurately reflects the patient’s clinical picture
- Support quality assurance initiatives through auditing and review of CDI work products
- Maintain detailed documentation within internal tracking and reporting systems
- Meet established productivity, accuracy, and quality standards
- Participate in ongoing education related to CDI, coding, compliance, and regulatory updates
- Perform additional duties as assigned
Qualifications
Education:
One of the following preferred:
- Associate or Bachelor’s Degree in Nursing
- Foreign Medical Graduate
- Bachelor’s Degree in Health Information Management
- Other related healthcare degree considered
Experience:
- Minimum 5 years of clinical healthcare experience
- Minimum 3 years of current inpatient CDI experience
- Prior experience performing CDI audits, quality reviews, or second-level reviews preferred
Credentials:
One or more of the following preferred:
- RN, BSN, CCDS, CDIP, CCS, RHIA, MD, or DO
Knowledge, Skills & Abilities
- Advanced knowledge of inpatient CDI practices, compliant query standards, and ICD-10 coding guidelines
- Strong analytical, auditing, and critical thinking skills
- Excellent written and verbal communication skills
- Ability to review complex clinical cases and provide actionable feedback
- Proficient with EMR systems, CDI software, and Microsoft Office applications
- Ability to work independently in a remote environment while managing multiple priorities and deadlines
- Strong organizational skills and ability to maintain collaborative professional relationships
Work Environment
This is a remote position requiring prolonged computer and phone use in a professional office setting. Minimal to no travel required.
