Position Summary
The Clinical Documentation Quality Reviewer plays a critical role in supporting Second Wave Delivery Systems' mission to ensure accurate clinical documentation, appropriate reimbursement, and a true reflection of the quality of care delivered. The primary focus of this position is the review of quality measures, including Patient Safety Indicators (PSIs), CMS Core Measures, and mortality cases, to identify documentation and coding opportunities that affect quality outcomes, publicly reported data, and risk-adjusted performance.
This is a team-based role. When quality review volume allows, the reviewer is expected to support the CDI query team by drafting, issuing, and managing compliant physician queries that clarify documentation, resolve coding ambiguities, and drive DRG and SOI accuracy. The reviewer collaborates closely with DRG Validation Auditors, Medical Directors, Query Writers, and revenue cycle analysts to ensure documentation reflects the complete clinical picture of patient care.
Key Responsibilities
Quality Measure Review (Primary Focus)
- Review inpatient records flagged for Patient Safety Indicators (including PSI-90 components) to validate whether the event is clinically supported, present on admission, or excluded, and identify documentation or coding opportunities.
- Review mortality cases to ensure documentation accurately captures severity of illness, risk of mortality, comorbidities, and palliative or hospice status that affect expected mortality and risk adjustment.
- Review records for CMS Core Measures to identify documentation gaps and ensure measure-related documentation is complete and accurate.
- Recommend coding changes or physician queries where documentation does not support, or does not fully explain, a quality event.
- Track and report findings, trends, and outcomes from quality reviews to support client reporting and provider education.
CDI Query Support (Team Support During Lower Quality Review Volume)
- Develop and issue compliant physician queries based on clinical indicators, coding guidelines, and documentation gaps.
- Review medical records to identify clarification opportunities that affect DRG assignment, SOI/ROM, and reimbursement integrity.
- Track and follow up on outstanding queries to ensure timely response and resolution.
General
- Ensure all queries and review findings adhere to AHIMA and ACDIS standards for compliance and neutrality.
- Collaborate with CDI professionals, inpatient coders, and quality teams to align documentation with coding and regulatory requirements.
- Maintain accurate records of review and query activity for audit and reporting purposes.
- Participate in education initiatives for providers on documentation best practices and quality measure impact.
- Perform other duties as assigned.
Qualifications
Education and Experience
- Prior experience as a Clinical Documentation Improvement Specialist within a hospital setting.
- Experience with quality measure review, including PSIs, mortality reviews, and/or CMS Core Measures, strongly preferred.
- Bachelor's degree or equivalent experience required.
- Clinical background or training as a Registered Nurse, Nurse Practitioner, Occupational Therapist, Physical Therapist, Physician Assistant, or Physician.
- Demonstrated experience working in an Electronic Medical Record (EMR) environment.
- Minimum of five years of recent hospital experience and/or verifiable documentation improvement expertise.
- Proficiency with 3M Encoder Systems.
- CCDS, CDIP, or similar credential preferred.
Knowledge, Skills, and Abilities
- Working knowledge of AHRQ PSI methodology, present-on-admission (POA) rules, and risk-adjustment concepts (SOI/ROM, expected vs. observed mortality).
- Strong understanding of coding guidelines, DRG assignment, and clinical terminology.
- Excellent written communication skills for clear, compliant query development and review findings.
- Ability to interpret clinical indicators and apply coding principles accurately.
- Detail-oriented with strong organizational and follow-up skills.
- Proficient in EHR systems and query management tools.
- Flexibility to shift between quality review and query work based on team needs.
Key Competencies
- Quality Focus: Understands how documentation affects quality outcomes, public reporting, and risk-adjusted performance.
- Compliance Focus: Adheres to regulatory standards and ethical query practices.
- Collaboration: Works effectively with physicians, coders, quality, and CDI teams, and steps in to support colleagues when priorities shift.
- Analytical Thinking: Identifies documentation gaps and interprets clinical data accurately.
- Communication: Crafts clear, concise, and compliant queries and review summaries.
Job Benefits
- Health insurance
- Vision insurance
- Dental insurance
- Life insurance
- Retirement plan
- Paid time off
Location: Remote
Compensation Range: $95,000 - $120,000
