Second Level Reviewer – Clinical Documentation Integrity

Guidehouse

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

Posted 9/15/2026full-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 (CDI) through comprehensive chart reviews, applying Official Coding Guidelines, and ensuring compliance with ACDIS and AHIMA standards. Proficient in analyzing clinical data, conducting audits, and collaborating with healthcare teams to enhance documentation quality and patient care.

Highest-signal resume keywords

Clinical Documentation Improvement (CDI)Official Coding GuidelinesCDIP or CCDS CertificationEHR Systems ProficiencyClinical Data Analysis

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical Chart ReviewDRG ValidationEncoder ExperienceCoding Quality ReviewDocumentation Gap AnalysisQuery WritingMortality ReviewHACs and PSIs KnowledgeClinical Validation PrinciplesCoding Compliance

Soft Skills

Verbal CommunicationWritten CommunicationCritical ThinkingCollaborationMentorship

Tools & Technologies

CDI SoftwareEHR SystemsCoding Encoders

Certifications & Qualifications

CCDSCDIPRegistered Nurse LicenseAHIMA Credentials (CCS, RHIA, RHIT)

Industry Keywords

MedicareMedicaidClinical DocumentationPatient Safety IndicatorsHospital Acquired ConditionsCoding ClinicsACDISAHIMACMS StandardsHealthcare Compliance

About the role

Key responsibilities & impact

Conduct comprehensive clinical chart reviews to ensure accurate reflection of patient care and diagnosis
Apply Official Coding Guidelines, Coding Clinics, client policies, ACDIS best practices and the CDI Code of Ethics
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 opportunities for improvement
Query providers using the concurrent query process under ACDIS/AHIMA compliant query-writing guidelines
Collaborate with CDI teams, Physician Advisors, providers, clinicians, Coding, Coding Educators, Coding Quality Auditors, Case Managers and Quality Department
Apply clinical validation principles and quality risk models during secondary reviews
Reconcile code and/or DRG assignment discrepancies as liaison between Coding and Clinical Documentation teams
Meet productivity, quality and turnaround expectations, including mailbox inquiries and mortality reviews
Collaborate with CDI educators and quality auditors to identify and address educational needs
Document and track secondary review results and share findings in education sessions
Conduct collaborative interactions with physicians and clinicians to improve understanding of CDI program goals
Perform impartial audits of front-line CDI documentation, provide feedback and mentorship, and escalate unresolved disagreements
Participate in committees, task forces and service line assignment meetings
Comply with HIPAA and code of conduct policies
Perform other duties as assigned

Requirements

What you’ll need

Graduation from accredited School of Nursing with BSN, ADN OR graduation from accredited medical school with MD or equivalent OR bachelor’s or master’s degree in health-related field
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, diagnoses/procedures, accurate clinical coding and billing
Knowledge of Medicare, Medicaid and commercial payor rules
Solid 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
CCDS or CDIP certification
Demonstrated verbal and written communication skills
Proficiency with EHR systems, CDI software and encoders
Knowledge of ACDIS and AHIMA compliant query guidelines
Knowledge of CMS and other regulatory standards
Ability to quickly learn and adapt to new technologies

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