Clinical Documentation Integrity – Second Level Reviewer

About the role

The Clinical Documentation Integrity (CDI) Second Level Reviewer conducts high‑level, complex secondary case reviews to ensure provider documentation accurately reflects patient severity, risk of mortality, and care complexity. This role supports UHealth initiatives by collaborating with CDI specialists, coders, quality analysts, and clinical teams.

Key responsibilities

• Perform timely secondary case reviews to identify documentation gaps and opportunities.
• Ensure clinical records meet regulatory standards and accurately capture severity of illness and risk of mortality.
• Apply knowledge of CMS star rating, Vizient, and US News risk‑adjustment systems to drive improvement.
• Complete quality reviews focused on mortality, Hospital Acquired Conditions, and other publicly reported metrics.
• Identify trends in querying, coding, and documentation integrity and recommend refinements.
• Utilize AHIMA/ACDIS query best practices to create clear, concise, compliant queries.

Required profile

• Strong critical‑thinking and judgment with focus on compliance, outcomes, and reimbursement.
• Ability to work collaboratively with multidisciplinary healthcare teams.
• Commitment to continuous quality improvement and regulatory adherence.

Required skills

• Proficiency with ICD‑10‑CM/PCS coding.
• Knowledge of APR DRG and MS DRG systems.
• Familiarity with CMS star rating, Vizient, and US News risk‑adjustment methodologies.
• Experience with AHIMA/ACDIS query practice guidelines.