Second Level Reviewer – Clinical Documentation Integrity

Guidehouse

. Conduct comprehensive clinical chart reviews to ensure accurate reflection of patient care and diagnoses .

Posted 11/2/2026full-timeRemote • United StatesMid-LevelSenior💰 $89,000 - $148,000 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in clinical documentation improvement, including conducting comprehensive chart reviews and applying clinical validation principles. Proficient in analyzing clinical data for documentation gaps and collaborating with healthcare professionals to enhance coding accuracy and compliance.

Highest-signal resume keywords

Clinical Documentation Improvement (CDI)DRG ValidationEncoder and DRG AssignmentsAHIMA Compliant Query GuidelinesEHR Systems Proficiency

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical Chart ReviewsDocumentation AnalysisQuality Risk ModelsCoding Quality ReviewDisease Process UnderstandingProvider Documentation RequirementsMedicare and Medicaid KnowledgeOfficial Coding GuidelinesCritical ThinkingMortality Models Understanding

Soft Skills

Excellent Verbal CommunicationExcellent Written CommunicationCollaborationMentorshipAdaptability

Tools & Technologies

CDI SoftwareEHR SystemsEncoders

Certifications & Qualifications

Registered Nurse (RN)AHIMA CCSAHIMA RHIAAHIMA RHITCDIPCCDS

Industry Keywords

Clinical DocumentationHospital Acquired Conditions (HACs)Patient Safety Indicators (PSIs)Coding ClinicHIPAA Compliance

About the role

Key responsibilities & impact

Conduct comprehensive clinical chart reviews to ensure accurate reflection of patient care and diagnoses
Perform secondary reviews of targeted patient populations, including DRG/code discrepancies, mortality reviews, HACs, PSIs and priority diagnoses
Analyze clinical data to identify documentation gaps, inconsistencies and improvement opportunities
Query providers using the concurrent query process according to ACDIS/AHIMA compliant query-writing guidelines
Apply clinical validation principles and quality risk models during secondary reviews
Collaborate with CDI staff, Physician Advisors, providers, clinicians, coding educators, coding quality auditors, case managers and the Quality Department
Reconcile discrepancies in codes and/or DRG assignments between Coding and Clinical Documentation Specialists
Meet second-level review productivity, quality and turnaround expectations, including mailbox inquiries and mortality reviews
Collaborate with CDI educators and quality auditors to identify educational needs
Document and track secondary review results and share findings in education sessions
Perform impartial audits of frontline CDI documentation, provide feedback and mentorship, and escalate unresolved disagreements
Participate in departmental and hospital committees, task forces and service line meetings
Contribute to a positive and collaborative working environment
Perform other assigned duties
Comply with HIPAA and code of conduct policies

Requirements

What you’ll need

Requires a University Degree and minimum 4-6 years of prior relevant experience; relevant experience may be substituted for formal education or advanced degree
Currently licensed as a Registered Nurse, MD or MD equivalent OR credentialed medical coder through AHIMA with current CCS, RHIA or RHIT credential and CDIP or CCDS
4-6 years previous relevant experience in clinical documentation, CDI second level review, inpatient coding quality review and/or DRG validation
Strong understanding of disease processes, clinical indications and treatments
Understanding of provider documentation requirements for severity of illness, risk of mortality and diagnosis/procedure support for accurate clinical coding and billing
Knowledge of Medicare, Medicaid and commercial payor rules
Understanding of hospital acquired conditions (HACs), patient safety indicators (PSIs) and mortality models
Must maintain credentials while employed
Strong clinical and critical thinking skillset
Experience with encoder and DRG assignments (MS and APR)
Working knowledge of Official Coding Guidelines, Coding Clinic and federal updates to the DRG system
Excellent verbal and written communication skills
Proficiency with EHR systems, CDI software and encoders
Knowledge of ACDIS and AHIMA compliant query guidelines
Ability to quickly learn and adapt to new technologies
Must comply with HIPAA and code of conduct policies

Benefits

Comp & perks

Medical, Rx, Dental & Vision Insurance
Personal and Family Sick Time & Company Paid Holidays
Position may be eligible for a discretionary variable incentive bonus
Parental Leave
401(k) Retirement Plan
Basic Life & Supplemental Life
Health Savings Account, Dental/Vision & Dependent Care Flexible Spending Accounts
Short-Term & Long-Term Disability
Tuition Reimbursement, Personal Development & Learning Opportunities
Skills Development & Certifications
Employee Referral Program
Corporate Sponsored Events & Community Outreach
Emergency Back-Up Childcare Program
Flexible benefits package
Flexible work arrangements (remote)