Job Description

Job Summary 

The Clinical Documentation Improvement (CDI) Specialist Lead provides advanced support for CDI activities within the facility, ensuring the accuracy, completeness, and integrity of clinical documentation to support appropriate coding, reimbursement, and quality outcomes. This role leads facility-level CDI efforts, supports education and mentoring of CDI team members, and collaborates with providers, coding teams, and clinical leaders to promote best practices in documentation. The CDI Specialist Lead is responsible for facilitating the achievement of organizational goals related to clinical documentation, data integrity, and regulatory compliance. 

Essential Functions

Leads CDI efforts at the facility level by supporting the accurate reflection of patient severity, acuity, and complexity through compliant documentation practices. Performs complex clinical documentation reviews and supports CDI team members with guidance, mentoring, and coverage as needed. Facilitates provider education and feedback related to documentation opportunities and best practices. Promotes adherence to compliant query guidelines in accordance with organizational policy, coding standards, and regulatory requirements. Collaborates with coding, HIM, quality, care management, and clinical teams to support accurate data reporting and optimal reimbursement. Monitors and reports on CDI Key Performance Indicators (KPIs), trends, and outcomes to facility and corporate stakeholders. Supports onboarding and continuing education of CDI staff; contributes to performance evaluation and skill development. Ensures appropriate use of CDI tools, query templates, and documentation systems in alignment with corporate standards. Maintains knowledge of evolving regulations, coding guidelines, and documentation requirements and communicates updates to stakeholders. Performs other duties as assigned. Complies with all policies and standards.

Qualifications

Associate Degree in Nursing or comparable clinical field required Bachelor's Degree preferred 4-6 years of acute care hospital nursing experience (e.g. medical/surgical unit, intensive care) required 2-4 years of experience in clinical documentation improvement, health information management, or inpatient coding required 1-3 years of provider or physician education experience required Experience in ICU/Critical Care, case management, utilization review, quality, or inpatient coding preferred

Knowledge, Skills and Abilities

Strong knowledge of disease processes, clinical care standards, and medical terminology Proficient in ICD-10-CM/PCS coding principles, MS-DRG and APR-DRG assignment, and the IPPS system Excellent verbal and written communication skills, with the ability to deliver feedback and education to physicians and multidisciplinary teams Strong critical thinking, prioritization, and problem-solving skills Skilled in use of CDI tools, encoder software, and electronic medical records Ability to mentor and support the professional growth of CDI staff Ability to work independently, manage time effectively, and meet deadlines Demonstrates professionalism, collaboration, and leadership in interdisciplinary environments

Licenses and Certifications

RN - Registered Nurse - State Licensure and/or Compact State Licensure or comparable clinical license/certification required or CCS-Certified Coding Specialist or ICD-10 certification or trainer designation required or Certified Clinical Documentation Specialist (CCDS) required RHIA - Registered Health Information Administrator preferred or RHIT - Registered Health Information Technician preferred CDIP - Clinical Documentation Improvement Professional preferred or Certified Coder-AHIMA or AAPC preferred