Job Summary and ResponsibilitiesAs our Team Lead, Clinical Documentation Integrity (CDI) you will provide essential day-to-day operational leadership and subject matter expertise for a team of dedicated CDI specialists. This pivotal role supports the CDI Market Manager in driving crucial documentation accuracy, quality outcomes, and regulatory compliance, while steadfastly promoting consistency with enterprise CDI standards across our healthcare system.
Every day you will serve as a vital clinical and coding resource, offering guidance and support to your team. You will assist with critical performance oversight, ensuring our CDI specialists meet high standards and contribute effectively to our revenue cycle optimization. Furthermore, you will actively foster collaboration across multidisciplinary stakeholders, enhancing communication and synergy in achieving accurate clinical documentation and improved patient outcomes. This position functions as a hands-on, working lead, actively participating in CDI tasks.
To be successful in this role, you will need a strong background in clinical documentation improvement, healthcare coding (e.g., ICD-10, CPT), and a deep understanding of clinical pathways and regulatory guidelines. We are seeking an experienced CDI professional with proven leadership potential, excellent communication skills, and the ability to mentor and guide a team towards achieving superior documentation integrity within a fast-paced healthcare environment.
- CDI Team Leadership & Support: Provides daily operational support, guidance, and functional leadership to assigned CDI staff, including workflow, prioritization, and issue resolution.
- Subject Matter Expertise: Acts as a CDI subject matter expert, assisting staff with complex cases, DRG validation, SOI, ROM, and identifying quality documentation opportunities.
- Performance Monitoring & Quality: Supports the CDI Market Manager in monitoring team performance, productivity, and quality metrics, contributing to improvement initiatives.
- Quality Assurance & Education: Reviews CDI work for accuracy, consistency, and compliance, and assists with onboarding, mentoring, and ongoing education for CDI specialists based on audit findings.
- Stakeholder & Workflow Collaboration: Serves as a liaison between CDI staff and key stakeholders (coding, quality, physician leadership) to promote documentation integrity and assists in developing CDI workflows and policies.
- Remote Work & Ethics: Promotes a professional, collaborative remote work environment, troubleshoots basic technology issues, and adheres to ethical standards set by ACDIS, AHIMA, and/or AAPC.
Job RequirementsRequired Qualifications:- Associate's degree in nursing, Health Information Management (HIM), or a related healthcare field
- Current CDI- or coding-related certification to be maintained, such as CCDS, CDIP, CCS, RHIA, RHIT, CIC, or equivalent
- Minimum of 3 years of recent CDI experience in an acute care hospital or large multi-facility healthcare system
- Demonstrated expertise in clinical documentation integrity, DRG methodology, SOI/ROM, and quality indicators
- Strong knowledge of anatomy and physiology, disease processes, medical terminology, and clinical documentation standards
- Experience working with electronic health record (EHR) systems (e.g., Epic, Cerner, Meditech)
- Background working with complex patient populations (e.g., trauma, cardiovascular, neurosurgery, or academic medical centers)
- Proven ability to work effectively in a fully remote environment
- Strong analytical, critical thinking, and problem-solving skills
- Excellent written and verbal communication skills, including the ability to provide clear, constructive feedback
Preferred Qualifications- Bachelor's degree in nursing, HIM, or a related healthcare field
- Prior experience in a CDI lead, preceptor, auditor, or informal leadership role
- Experience supporting CDI quality audits or performance improvement initiatives
- Familiarity with middle revenue cycle operations and downstream coding or billing impacts
Where You'll Work 
