Clinical Documentation Integrity Lead – Service Line

This is a fully remote position, open to applicants in California.

📋 Description

• Manage and enhance relationships between CDI and designated service lines, holding regular meetings with physician champions and chairs/chiefs.

• Monitor and escalate inquiries to enhance workflow efficiency and query response times.

• Conduct targeted CDI audits and analyze findings related to documentation and coding practices.

• Develop physician education programs, identify opportunities at both individual and service-line levels, and facilitate both short- and long-term solutions.

• Act as a subject matter expert on CDI methodologies, coding regulations, compliance risks, and documentation enhancements.

• Assess and monitor CDI and coding quality in alignment with best practices.

• Complete project-related assessments and provide constructive feedback to colleagues, coding teams, CDI leadership, and quality partners.

• Oversee data collection and analysis concerning patient care activities, documentation and coding opportunities, and clinical outcome discrepancies.

• Organize multidisciplinary working sessions aimed at goal setting and problem-solving.

• Enhance service-line CDI programs and design, deliver, and assess educational offerings for providers and multidisciplinary teams.

• Lead multidisciplinary and multi-departmental CDI initiatives to achieve strategic objectives.

• Collaborate with CDI leaders, IT, and technology partners to optimize documentation tools and processes, thereby reducing the administrative burden on providers.

⛳️ Requirements

• Bachelor’s degree in Nursing, Medicine, Health Information Management, or a closely related field.

• A minimum of two active certifications from the specified certification categories, including COC, CPC, CCS, CDMP, CAP, CRCR, HACP, CPHQ, HCQM, CCM, clinical certification, PECP, or other educational certifications.

• Five years of progressively responsible and directly related inpatient clinical experience.

• At least five years of experience in CDI or provider education.

• Proficient in outcomes data reporting and analysis.

• A currently active CCDS, CCDS-O, or CDIP certification is required.

• Expertise in coding and CDI practices, as well as Medicare/Medicaid regulations, CMS coding guidelines, MS-DRGs, APR-DRGs, HCCs, ICD-10-CM/PCS, and AMA CPT coding standards.

• Extensive knowledge and experience with computer systems, reporting software, and electronic medical record (EMR) systems.

• Strong leadership, organizational, critical thinking, interpersonal, and communication skills, both verbal and written.

• Familiarity with project management, statistical analysis, quality improvement, and program evaluation.

• Capability to develop and present training and education to clinical, CDI, and coding professionals.

• Experience in an ICU/ED and Academic Medical Center setting is preferred.

• Background in case management, utilization review, direct provider interaction, public speaking, and multidisciplinary education is preferred.

• Experience with Vizient, Premier, Elixhauser, and other risk adjustment methodologies is highly preferred.

• Nursing/RN state or compact-state licensure is preferred.

🏝️ Benefits

• Competitive salary and comprehensive health benefits.

• Opportunities for professional development and continuing education.

• Supportive work environment promoting work-life balance.