The Inpatient Clinical Documentation Specialist Second Level Reviewer (CDS SLR) will work under the direction of the Clinical Documentation Improvement (“CDI”) Manager and alongside the CDS Lead to assist with the oversight of the CDI process and team, conduct spot checks of the CDS team’s queries and reviews for compliance and effectiveness, provide feedback and education to the CDS team based on the second-level reviews and spot checks, assist with the query escalation process, identify and implement process improvements for the CDI program, and provide monitoring and oversight of productivity. The CDS SLR supports the objective for accurate reflection of patient acuity, severity of illness, risk of mortality, and DRG assignment in compliance with industry rules and regulations.

• Monitor day-to-day/weekly productivity of CDI team in the absence of or unavailability of the CDI Manager/CDS Lead
• Assist with the scheduling of staff, and if necessary, redistribution of cases to assure appropriate coverage (e.g., when a CDS is out of the office, high census on certain units) in the absence of or unavailability of the CDI Manager/CDS Lead

• Provide feedback to CDI Manager/Director and CDS Lead on operational concerns

• Work with CDS Lead to facilitate which unanswered queries or those with an incomplete response get escalated to physician advisors

• Serve as a lead point of contact for the Physician Advisors

• Serve as a lead point of contact in the absence of or unavailability of the CDI Manager/Director/CDS Lead

• Assist CDS Lead to review queries with unfavorable responses (disagree or unable to determine) to determine if they are effectively written and clinically appropriate

• Assist CDS Lead to provide education and feedback to CDS or Physician Advisor, as applicable

• Assist CDS Lead to strategize approach and process refinements to capture opportunity with the CDS team (prioritization, assignment, use of tools, etc.)
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• Assist CDS Lead to facilitate DRG mismatch reconciliation process when CDS and coder cannot agree

• Assist CDS Lead to coordinate with Coding Manager if mismatch is coding in nature
• Assist CDS Lead, CDI Manager and CDI Director to develop and oversee new hire training and orientation program for new CDSs
• Assist CDS Lead to review new CDS queries for compliance and effectiveness and spot check charts for appropriate opportunity identification

• Provide feedback and educational growth opportunities to the CDI team

• Coordinate with CDS Lead, CDI Director, CDI Manager, and Physician Advisors to determine individual physician and service line educational needs. Coordinate with CDI Manager and Physician Advisors to participate in new provider orientation, resident orientation and provider outreach

• Assist CDS Lead and/or CDI Manager with education topics for weekly CDI huddle or monthly joint CDI/Coding meetings
• Attend meetings/calls as requested
• Conduct quarterly audits of each CDSs reviews and queries for compliance and effectiveness, and spot check charts for appropriate opportunity identification as needed
• Maintain a summary of opportunities identified through second-level reviews and audits for feedback and education with the CDS team

• Compile trends and areas of opportunity and conduct education with the CDS team based on the findings

• Periodically 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

Education
Registered Nurse, Preferred BSN but not required

Minimum Work Experience
Minimum of two (2) years' of experience in a managerial position in a clinical setting preferred. Minimum of two (2) consecutive years of experience in clinical documentation.

Required Skills, Knowledge, and Abilities
Strong Professional, organizational, and interpersonal skills required for effective and creative leadership in working with all levels of the Organization.

Ability to lead, support and build on current efforts of various groups working within the department’s scope of work.

Function independently under the guidance of the System Manager/Director within the broad scope of department and organization-wide policies, practices and common goals.
Work with CDI System Manager/CDI System Director and CDS Lead to develop and oversee new hire training and orientation program for new CDSs
Review new CDS queries for compliance and effectiveness and spot check charts for appropriate opportunity identification
Provide feedback and educational growth opportunities to the CDI team
Coordinate with CDI Director, CDI Manager, CDS Lead and Physician Advisors to determine individual physician and service line educational needs. Coordinate with CDI Manager and Physician Advisors to participate in new provider orientation, resident orientation and provider outreach
Assist CDI Manager and CDS Lead with education topics for weekly CDI huddle or monthly joint CDI/Coding meetings