Clinical Documentation Integrity Specialist

What You Will Do

Clinical Documentation Integrity (CDI) Second Level Reviewer responsibilities include comprehensive, clinical chart reviews to ensure the most accurate reflection of the patient\'s care and diagnosis following Official Coding Guidelines, Coding Clinics, and UAB policies. The CDI Second Level Reviewer collaborates closely with the CDI team, Physician Advisors, Providers, Clinicians, Coders, Coding Educator, Coding Quality Auditors, Case Managers and Quality Department to assure documentation is clinically appropriate, accurately reflects the severity of illness and risk of mortality, and is reflective of current CMS or other regulatory standards. The role applies the Association of Clinical Documentation Integrity Specialist (ACDIS) best practices for writing clinical documentation integrity clarifications and follows the CDI Code of Ethics. It also collaborates with CDI Management/Educator to identify opportunities for education with the CDI team, Coding, Providers and/or other ancillary staff to improve the overall quality and completeness of documentation.

The CDI Second Level Reviewer role is dynamic, requiring adaptation to various clinical and administrative needs. This flexibility is essential for effectively addressing evolving challenges in clinical documentation, ensuring the accuracy and compliance of patient records. The incumbent will navigate multiple responsibilities with agility, participating in diverse projects and initiatives that enhance documentation quality and patient care 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.
• Completes 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.
• Consistently meet second level review productivity, quality, and turnaround expectations, including mailbox inquiries and mortality reviews, to support Guidehouse client metrics.
• 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.
• Communicate findings from secondary reviews to Clinical Documentation Specialists for follow-up and query initiation and education; and collaborate with CDI educator and quality auditors to identify and address educational needs.
• Document and track the results of secondary reviews, sharing information during formal and informal education sessions to all stakeholders (CDI, Leadership, Physicians), via engaging in collaborative interactions with physicians and other clinicians to enhance understanding of CDI program goals.
• Collaborative interaction with physicians and/or other clinicians to enhance understanding of the CDI program goals; ensure the medical record can be coded accurately to reflect patient severity of illness and risk of mortality.
• Perform impartial audits of front-line CDI documentation using Guidehouse criteria, provide professional feedback and mentorship, and escalate unresolved disagreements through appropriate leadership channels.
• Complete second level reviews of specific patient populations (per UAB guidance) to identify documentation improvement opportunities, accurate selection of principal and/or other diagnosis, procedures and present on admission status (when appropriate).
• Acts as a liaison between the Coding Department and the Clinical Documentation Specialist to reconcile discrepancies in code and/or DRG assignment.
• Seasoned technical individual contributor: works independently on large or complex projects and assignments, with minimal guidance.
• Works to influence parties within and outside of the job function at an operational level regarding policies, practices, and procedures.
• Problems and issues faced are difficult and may require understanding of broader set of issues. Problems typically involve consideration of multiple issues, job areas or specialties and are solved through prior experience and analysis.

• Graduation from an accredited School of Nursing with BSN, ADN OR Graduation from an accredited medical school with MD or equivalent OR Bachelor\'s or Master\'s Degree in health-related field. (Relevant experience may be substituted for formal education or advanced degree)
• Currently licensed or licensed by endorsement as a Registered Nurse, MD or MD equivalent OR Credentialed Medical Coder through AHIMA with current CCS, RHIA or RHIT credential and CDIP or CCDS
• 4-6 years of previous relevant experience in clinical documentation, CDI second level review, inpatient coding quality review and/or DRG validation 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 to the rules of Medicare, Medicaid, and commercial payors; plus a solid understanding of hospital acquired conditions (HACs), patient safety indicators (PSIs) and mortality models.
• Must maintain credentials while employed

• CCS
• CCDS or CDIP certification
• Previous Vizient experience
• Previous Optum CAC experience
• Strong clinical and critical thinking skillset
• 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
• Ability to conduct meaningful conversations and/or presentations with providers in all situations
• Excellent communication skills, with ability to listen and understand client requests and needs while employing tact and effectiveness

• Medical, Rx, Dental & Vision Insurance
• Personal and Family Sick Time & Company Paid Holidays
• Position may be eligible for a discretionary variable incentive bonus
• Parental Leave
• 401(k) Retirement Plan
• Basic Life & Supplemental Life
• Health Savings Account, Dental/Vision & Dependent Care Flexible Spending Accounts
• Short-Term & Long-Term Disability
• Tuition Reimbursement, Personal Development & Learning Opportunities
• Skills Development & Certifications
• Employee Referral Program
• Corporate Sponsored Events & Community Outreach
• Emergency Back-Up Childcare Program

Guidehouse is an Equal Opportunity Employer. Protected Veterans, Individuals with Disabilities or any other basis protected by law, ordinance, or regulation.

Guidehouse will consider for employment qualified applicants with criminal histories in a manner consistent with the requirements of applicable law or ordinance including the Fair Chance Ordinance of Los Angeles and San Francisco.

If you require an accommodation, please contact Guidehouse Recruiting at or via email at All information provided will be kept confidential and used only to provide needed reasonable accommodation.

All recruitment communications will come from Guidehouse domains including @guidehouse.com or Do not respond to correspondence from other domains. Guidehouse will never charge a fee or request money transfers at any stage of the recruitment process.

If any person or organization demands money related to a job opportunity with Guidehouse, please report the matter to Guidehouse\'s Ethics Hotline. To verify the validity of correspondence, contact Guidehouse is not responsible for losses incurred from dealings with unauthorized third parties.

Guidehouse does not accept unsolicited resumes through or from search firms or staffing agencies. All unsolicited resumes will be considered the property of Guidehouse and Guidehouse will not be obligated to pay a placement fee.