The CDI Second Level Reviewer is an experienced Clinical Documentation Specialist responsible for performing advanced, targeted case reviews on potentially high-impact encounters. This role focuses on identifying documentation opportunities in complex or high-risk cases to ensure accurate representation of patient acuity, quality outcomes (such as expected mortality), and financial performance. This role serves as an escalation and quality layer beyond concurrent review. This role will coordinate closely with CDI leadership and the CDI Educator to identify trends and provide feedback to the concurrent review team on findings.

Job Responsibilities

• Perform secondary reviews of cases with a high potential impact, including but not limited to:
  • Length of stay variance from expected (GMLOS) without documented comorbidities
  • Low acuity diagnoses with longer than expected length of stay
  • Unexpected mortalities and hospice discharges
  • Mortality risk variable opportunity cases
  • Other quality reviews such as PSIs or HACs
• Identify and act on missed documentation opportunities impacting severity, risk adjustment, and reimbursement
• Send queries to clarify documentation when appropriate
• Deliver feedback and education to concurrent CDI staff on findings in coordination with CDI Educator and/or CDI leadership
• Analyze trends and patterns to support quality and performance improvement initiatives
• Partner with CDI leadership to refine review criteria and escalation processes
• Ensure alignment with coding guidelines and organizational priorities
• Collaborate with coding and CDI Physician Advisors, as needed, on cases with potential opportunities identified in second level reviews

Required Qualifications

• Licensed in NYS, RN, NP or PA who is a credentialed Clinical Documentation Specialist CCDS, or CDIP
• Experience – minimum of 5 years recent CDI experience.
• Demonstrated advanced CDI knowledge and strong clinical foundation
• Proven experience in concurrent CDI review
• Strong understanding of DRG methodology, quality metrics, and documentation impact
• Excellent critical thinking and communication skills
• Preferred Epic EMR and 3M 360 application proficiency

Desired Attributes

• High level of clinical and coding expertise
• Ability to identify nuanced documentation gaps in complex cases
• Detail-oriented with strong problem-solving skills
• Collaborative mindset with ability to educate and influence peers
• Comfortable working independently in a specialized review workflow
• Strong sense of accountability and ownership for high-impact work

Deliverables

• Completion of timely, high-quality second-level reviews for prioritized cases
• Identification and capture of documentation opportunities that impact quality and financial outcomes
• Feedback provided to CDI team based on review findings in coordination with CDI Educator and CDI leadership
• Contribution to improved documentation and quality metrics
• Regular reporting of trends, opportunities, and outcomes from second-level reviews