Description

Clinical Documentation Coordinator / Second Level Reviewer (Remote)

FullTime | 80 Hours per Pay Period Bronson Healthcare Group

Love Where You Work

Team Bronson is compassionate, resilient and strong. We are driven by Positivity, inspiring us to be our best for our patients, for one another and for our community. If you’re ready for a rewarding new career, join Team Bronson and be part of the experience.

Position Summary

The Clinical Documentation Coordinator / Second Level Reviewer (SLR) is a professional CDI with strong clinical knowledge and an advanced understanding of DRG documentation requirements. Working under the supervision of the CDI Manager, this role performs secondary clinical chart reviews, resolves DRG discrepancies and provides education to clinical staff on documentation accuracy, diagnosis clarification and improved capture of comorbid conditions.

The SLR conducts concurrent and retrospective medical record reviews to identify opportunities to improve documentation accuracy and collaborates closely with the Coding Department to ensure documentation is clinically appropriate, reflects severity of illness and aligns with current CMS standards.

Responsibilities

• Conduct comprehensive secondary clinical chart reviews to identify missed opportunities for documentation clarification
• Serve as liaison between Coding and CDI to resolve DRG or coding discrepancies
• Collaborate with the CDI Manager to educate the CDI team based on review findings
• Work directly with clinicians and providers to improve documentation quality and completeness through queries and education
• Ensure documentation accurately reflects severity of illness, risk of mortality and regulatory standards
• Analyze and interpret clinical data to identify gaps, inconsistencies or opportunities for improvement
• Initiate compliant provider queries following ACDIS and AHIMA guidelines
• Complete secondary reviews for targeted populations including DRG discrepancies, mortality reviews, HACs, PSIs and other priority diagnoses
• Communicate review findings to CDI Specialists for followup and query initiation
• Collaborate with physicians, quality, case management and coding teams to ensure highquality documentation and timely coding

Shift and Schedule

First Shift Full Time Scheduled Weekly Hours: 40

Requirements

Requirements

Education and Skills

• Bachelor’s degree required
• Graduation from an accredited School of Nursing; BSN or bachelor’s degree in a healthrelated field preferred

Experience

• Minimum of 3 to 5 years as a Clinical Documentation Integrity Specialist required
• Strong clinical and critical thinking skills
• Experience as a CDI Specialist or Second Level Reviewer with deep understanding of disease processes, clinical indications, treatments and provider documentation requirements
• Knowledge of severity of illness, risk of mortality, HACs, PSIs and mortality models
• Experience with encoder systems and DRG assignments (MS and APR)
• Working knowledge of Official Coding Guidelines, Coding Clinic and federal DRG updates

Licenses and Certifications

• Licensed RN, MD or MD equivalent
• CDIP or CCDS certification required or obtained within six months