Clinical Documentation Improvement Lead, Day Shift, Patient Clinical Documentation
Core
Examine medical records to ensure documentation is accurate, complete, and reflective of the patient's clinical status; detect inconsistencies and request provider clarifications to support correct coding and compliance.
Role type
Senior Clinical Documentation Improvement (CDI) Lead
Builds
Accurate medical records supporting ICD-10-CM/PCS and CPT coding for reimbursement and regulatory compliance
Domain
Healthcare / Clinical Documentation & Revenue Cycle
Required skills
Medical record review, Provider query management, ICD-10-CM/PCS coding, CPT coding, CMS guideline compliance, Quality improvement initiatives, Data analysis for program metrics, Case-specific education delivery, Audit support, Continuing education
Preferred skills
Lean Six Sigma Green belt, Solventum360 proficiency, Inpatient clinical experience, Acute-care clinical experience
Technologies
Solventum360, ICD-10-CM, PCS, DRGs, SOI/ROM, HCC
Responsibilities
Examine medical records for accuracy and completeness; Detect inconsistencies and request provider clarifications; Verify documentation supports correct coding; Ensure alignment with regulatory standards; Communicate with physicians to improve documentation practices; Support denial prevention and medical necessity validation; Contribute to quality improvement initiatives (MHACs, PPCs, PSIs, SOI/ROM, mortality); Maintain productivity and quality logs; Provide case-specific education to providers; Assist in internal and external audits; Maintain clinical documentation knowledge via continuing education.
Seniority
Senior, hands-on IC