Clinical Documentation Integrity Lead

We are seeking a Lead Clinical Documentation Integrity Specialist to take charge of our CDI program's day-to-day operations. In this role, you will collaborate closely with CDI Specialists, department heads, and healthcare providers to ensure the accuracy, completeness, and quality of medical record documentation. By conducting thorough audits, providing education, and analyzing data, you will drive improvements in documentation practices while ensuring compliance with coding standards and regulatory requirements. Your leadership will be instrumental in fostering a culture of collaboration and continuous improvement within our CDI program.
Key Responsibilities:

• Lead and oversee the Clinical Documentation Integrity (CDI) program, working closely with CDI Specialists, department leadership, and healthcare providers.
• Conduct audits and investigations to identify areas for improvement in medical record documentation.
• Provide education and training to healthcare providers and CDI staff to enhance documentation practices.
• Analyze data to identify trends and opportunities for improving documentation quality and accuracy.
• Collaborate with physicians, coders, and other healthcare professionals to ensure appropriate code assignment and reimbursement.
• Perform pre-bill compliance audits to ensure accurate code assignment and adherence to regulatory requirements.
• Maintain up-to-date knowledge of coding guidelines, regulations, and industry best practices.
• Foster a collaborative and supportive environment within the CDI team.

Qualifications:

• Minimum of four (4) years of experience as a Clinical Documentation Integrity Specialist.
• Bachelor's degree in a relevant field preferred (BSN); alternatively, an Associate of Science in Nursing (ASN) degree with two (2) years of relevant clinical experience in an acute care inpatient setting.
• Active Florida Registered Nurse (RN) license or Medical Doctor (MD) equivalent.
• Certified Documentation Improvement Practitioner (CDIP) or Certified Clinical Documentation Specialist (CCDS) certification within one (1) year of hire, with ongoing maintenance of required Continuing Education Units (CEUs).

Preferred Qualifications:

• Strong verbal and written communication skills.
• Ability to work effectively in a team environment and delegate tasks as needed.
• Strong decision-making skills and ability to prioritize tasks effectively.
• Ability to remain composed under pressure and engage effectively with healthcare providers.
• Proficiency in coding with experience in ICD-10-CM and familiarity with the AHA Coding Clinic.
• Previous experience as a Clinical Documentation Integrity Auditor/Educator.