Clinical Documentation Integrity Lead (CDI Lead)

Job Description

Networks Connect is conducting a search for a local prominent healthcare system for someone to join their dynamic healthcare team as a Clinical Documentation Integrity Lead! Leverage your expertise in clinical documentation, compliance, and healthcare coding to spearhead our CDI program. This role is crucial in enhancing the accuracy, quality, and completeness of medical record documentation.

Key Responsibilities:

• Lead day-to-day operations of the Clinical Documentation Integrity program.
• Collaborate with CDI Specialists, department heads, and healthcare providers (including Physicians, Advanced Practice Professionals, and Medical Residents) to enhance medical record documentation.
• Conduct thorough audit investigations, educational initiatives, and data analysis to ensure documentation quality.
• Work closely with medical coders and healthcare staff to ensure accurate coding and appropriate charge capture.
• Perform pre-bill compliance audits, adhering to coding guidelines and regulatory requirements.
• Proactively identify and resolve issues impacting data quality and reimbursement accuracy.

Required Qualifications:

• At least four years of experience as a Clinical Documentation Integrity Specialist.
• Bachelor’s degree in Nursing (BSN) or Associate of Science in Nursing (ASN) with two years of relevant clinical experience.
• Active Florida RN or MD license.
• Obtain CDIP or CCDS certification within one year.

Preferred Qualifications:

• Experience in Clinical Documentation Integrity Auditing/Education.
• Proficiency in ICD-10-CM coding and AHA Coding Clinic.
• Excellent communication and team collaboration skills.
• Ability to work independently and manage multiple tasks effectively.
• Familiarity with payer compliance and quality metrics.

Key Job Standards:

• Comprehensive management of daily CDI operations, including chart audits and query resolutions.
• Development of CDI educational programs for staff and physicians.
• Advanced use of CDI software and maintaining data integrity.
• Active involvement in quality assurance and process improvement initiatives.
• Ensuring compliance with all relevant healthcare regulations and standards.

Earnings

N/A

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Revenue Cycle