Lead Clinical Documentation Specialist

Job Summary

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

Key Responsibilities

• Assist in planning and directing day-to-day operations of the CDI program
• Facilitate improvement in the quality, completeness, and accuracy of medical record documentation through audits and education
• 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 with two (2) years of 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 and predictable attendance is required