Lead Clinical Documentation Improvement Specialist

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Job Details

Lead Clinical Documentation Improvement Specialist

Job Overview

Lead Clinical Documentation Improvement Specialist


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Lead Clinical Documentation Improvement Specialist

The Lead Clinical Documentation Improvement Specialist oversees quality and process program metrics. The goal of the Lead role is to ensure technical documentation and workflow knowledge of clinical documentation specialists and inpatient providers.

The Lead serves as the primary point for CDI data requests and provides back up support to the Director, CDI. The CDI Lead uses clinical, coding, analytical, and project management expertise to ensure the CDI program meets AHIMA/ACDIS/CMS guidelines. The Lead uses analytical skills to construct and run quality studies and reports. The Lead also facilitates community-building with CDI Program team members and partners.

The Lead CDS collaborates with CDI program leadership to develop and implement growth and improvement initiatives with focus on education and building adoption among clinical documentation specialist, coding, inpatient providers, and quality partners.

Key Responsibilities

  • Essentially the righthand for the Director of CDI
  • No mandatory daily chart review assignment
  • Mentor CDI Specialists
  • Act as a daily resource for CDI staff
  • Orient new hires
  • Provide coverage for staff in their absence
  • Assist with staff evaluations and scheduling
  • Perform query audits and second level reviews
  • Back up for Director with meetings
  • Assist with new provider orientation
  • Attend Quality meetings and review groups
  • Keep up with 3M updates
  • Lead team huddles every Monday, Wednesday, and Fridays


  • RN with 3-5 years of CDI experience and 5 years of direct nursing experience with preference to ED or critical care.
  • Licensed as Registered Nurse in State of New Mexico or compact state.
  • BSN or RN with bachelor’s degree required or must obtain within five years from hire date.
  • Excellent written and verbal communication skills.
  • Developed Critical thinking and analytical ability required.
  • Experience with database, spreadsheet and word process required.
  • Detail and results oriented with the ability to maintain accurate, detailed, and organized records is essential.
  • Ability to work independently and make independent decisions.
  • Working knowledge of medical terminology, ICD-10, CPT, HCPSC and DRG required. Must possess knowledge of disease processes and related procedures.
  • Up to date clinical skills and current working knowledge of pathology and pharmacology impacts on care required.
  • Experience in working directly with physicians, including knowledge of conflict resolution techniques preferred.
  • Ability to identify physician perceptions and/or concerns and act on this information in a tactful manner.
  • Able to maintain composure when dealing with physicians and hospital staff.
  • Must possess excellent clinical skills, advanced problem-solving ability and is able to role model and teach others in a non-threatening supportive manner.
  • Maintain positive interdepartmental relations and develop
  • CCDS or CDIP required or must obtain within one year of hire.



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