Lead Clinical Documentation Specialist

Job Summary

A company is looking for a Lead CDI Specialist to oversee the Clinical Documentation Integrity program and improve the quality of medical record documentation.

Key Responsibilities

• Assist leadership in planning and directing day-to-day operations of the CDI program
• Facilitate improvement in medical record documentation quality through audits, education, and data analysis
• Perform pre-bill compliance audits and ensure accurate code assignment and compliance with regulations

Required Qualifications

• Minimum of three (3) years of experience as a Clinical Documentation Integrity Specialist
• Bachelor's degree (preferably BSN) or an Associate of Science in Nursing (ASN) with relevant clinical experience
• Certification as a Certified Documentation Improvement Practitioner (CDIP) or Certified Clinical Documentation Specialist (CCDS) within one (1) year
• Proficiency in Microsoft Excel and Outlook
• Regular, predictable attendance is required