Clinical Documentation Specialist 3 (Second-Level Reviewer)

Clinical Documentation Specialist 3

Inova Benefits and Perks :

• Health, Vision, and Dental Coverage
• Tuition reimbursement and Educational Assistance
• Student loan assistance - up to $10,000!
• Paid parental leave for birth / adoption of a child
• Retirement benefits with match from day one
• Exclusive savings opportunities to in-store events, theme parks, discounts, movie tickets and local offerings and so much more!
• Competitive salary : Pay based experience
• Amazing Paid Time Off : Accrue PTO hours on your very first day of work

See Full List of Benefits Here : 2024 INOVA BENEFITS GUIDE

Inova Health System is seeking a Clinical Documentation Specialist (Second-Level Reviewer) to join the Central CDI team! This role is REMOTE working Full time hours Monday to Friday.

Requirements for consideration :

• Associate Degree (or RN, MD, RHIA, RHIT)
• 5 years of professional inpatient acute care, inpatient clinical, and / or coding experience required. Includes ICU, ER, Peds / NICU, case management / UR, quality, or similar level of advanced care / coding.
• 3 years of CDI experience in an acute inpatient healthcare setting.
• CDI certification (CCDS or CDIP).
• RN, RHIA / RHIT, or foreign medical school licensure documentation equivalent to educational background required.

Job Responsibilities included but not limited to :

Performs initial case reviews and an appropriate number of follow-up reviews based on program standards. Uses clinical insight and judgment of clinical findings to assess clinical documentation for improvement opportunities.

Follow-up with the physician responsible for care of the patient, via the query process, for clarification of clinical significance and appropriate documentation..

Participates in special projects, audits, and other duties as directed by CDI Leadership including but not limited to 2nd level reviews for mortality, PSI, HAC, readmission and / or audits for focus DRGs, reconciliation / validation of CDI statistics / outcomes, precepting new team members, reviewing and updating policy & procedure;

reviewing & updating query templates; leading service line or department provider education initiatives..

• Supports CDI team members as a key resource and subject matter expert on clinical topics and CDI opportunities.
• Assists CDI Manager and CDI Educator / Auditor in identifying CDI team's continuing educational needs.
• Participates in the education and onboarding process of CDS 1 and CDS 2 team members as assigned.
• Participates in organizational initiatives and performance improvement projects as assigned. Works with the CDI Manager and CDI Educator / Auditor to support the implementation of policies and procedures, audit recommendations, and new CDI strategies by team members.
• Assists Lead CDS, CDI Manager, and CDI Director with short and long-term, strategic planning for the CDI team, identifying potential and / or actual barriers and / or opportunities to enhance the success and growth of the CDI team consistent with Inova's mission, vision and values.
• Maintains current knowledge of trends, regulations, and technology related to documentation, coding, reimbursement, and regulatory guidelines through professional journals, informal networks, internet sites, and local, state, and national professional associations.

Reviews professional CDI and coding literature regularly.

• Works collaboratively with medical, nursing, and ancillary staff to improve the quality of chart documentation that assures appropriate DRG classification to accurately reflect patient severity of illness and risk of mortality.
• As needed, may travel across the Washington DC metro area to engage with providers.
• May perform additional duties as assigned.
7 hours ago