Clinical Documentation Integrity Lead – Service Line

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

📋 Description

• Collaborate with service line and physician leadership to enhance documentation tools, streamline processes, and alleviate administrative burdens for providers.

• Manage and strengthen relationships between Clinical Documentation Improvement (CDI) and designated service lines.

• Conduct regular meetings with service line physician champions and chairs/chiefs.

• Monitor and escalate queries to enhance workflow efficiency and reduce query turnaround time.

• Execute targeted CDI audits and analyze results related to documentation and coding practices.

• Develop physician education programs and identify opportunities for individual and service line improvement.

• Act as a subject matter expert on CDI methodologies, coding regulations, and standards.

• Perform compliance risk assessments and pinpoint documentation enhancement opportunities.

• Evaluate CDI and coding quality against established best practices.

• Complete project-related reviews and offer feedback to peers, coding teams, CDI leadership, and quality partners.

• Coordinate data collection and analysis pertaining to patient care, documentation, coding, and clinical outcome discrepancies.

• Organize multidisciplinary working sessions focused on goal setting and problem-solving.

• Enhance service line CDI programs and create, deliver, and assess education for providers and multidisciplinary teams.

• Lead CDI projects that involve multiple departments and disciplines.

• Collaborate with CDI leaders, IT, and technology partners to develop and refine documentation tools, processes, and strategies.

⛳️ Requirements

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

• A minimum of two active certifications from the specified certification categories.

• At least 5 years of progressively responsible and relevant inpatient clinical experience.

• Minimum of 5 years of experience in CDI or provider education-related roles.

• Experience in outcomes data reporting and analysis.

• Proficiency in coding and CDI practices.

• Comprehensive knowledge of Medicare/Medicaid rules and regulations.

• Familiarity with CMS coding guidelines and methodologies, including MS-DRGs, APR-DRGs, HCCs, CM/PCS, and AMA CPT coding guidelines.

• Extensive experience with computer systems, reporting software, and electronic medical record systems.

• Proven leadership skills, organizational capability, and critical thinking abilities.

• Strong collaborative, interpersonal, and communication skills, both verbal and written.

• Understanding of project management processes and systems.

• Knowledge of statistical analysis and reporting practices.

• Expertise in developing and conducting training and educational programs.

• At least one active certification: CCDS, CCDS-O, or CDIP.

• Preferred experience in ICU/ED and Academic Medical Centers.

• Preferred experience in case management, utilization review, and/or direct provider interactions.

• Preferred experience in public speaking and formal multidisciplinary education.

• Highly preferred experience with Vizient, Premier, Elixhauser, and other risk adjustment methodologies.

🏝️ Benefits

• Competitive salary and performance-based bonuses.

• Comprehensive health, dental, and vision insurance.

• Retirement savings plan with employer matching.

• Opportunities for professional development and continuing education.

• Flexible work arrangements and a supportive work environment.