Lead Clinical Documentation Improvement Specialist - Remote

Overview

The Lead Clinical Documentation Improvement Specialist is responsible for enhancing the quality of medical record documentation, ensuring accurate coding, and providing education to healthcare providers.

In Short

• Perform concurrent and retrospective reviews of medical records.
• Identify opportunities for improving documentation quality.
• Complete audits for query compliance and coding accuracy.
• Provide education and training for compliance and competency.
• Develop and manage education curriculum for CDI specialists.
• Participate in interdisciplinary work groups as a subject matter expert.
• Ensure adherence to JCAHO, CMS, and third-party payer guidelines.
• Maintain RN licensure and CCDS or CDIP certification.
• Utilize excellent communication and team collaboration skills.
• Engage in quality assurance and process improvement initiatives.

Requirements

• Bachelor’s degree in nursing and active RN license.
• 6 years of relevant experience required; 6-10 years preferred.
• Certification as CCDS or CDIP.
• Experience in Clinical Documentation Integrity Auditing.
• Proficiency in ICD-10-CM/PCS coding.
• Ability to work independently and manage multiple tasks.
• Familiarity with payer compliance and quality metrics.

Benefits

• Comprehensive medical, dental, and vision insurance.
• Tuition assistance for employees and dependents.
• State or alternative retirement options with competitive contributions.
• Supportive work environment focused on academic achievement and innovation.
• Opportunities for professional development and career growth.