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The CDI RN Lead serves as a clinical subject matter expert and frontline leader for the Clinical Documentation Improvement program. This role is responsible for coordinating program elements, mentoring staff, and driving physician engagement to ensure documentation accurately reflects patient complexity, severity of illness, and risk of mortality. The Lead ensures the program aligns with compliance standards and organizational goals while fostering a culture of continuous improvement.
Acts as a primary point of contact for the CDI team; coordinates and maintains all program elements to meet organizational goals and balanced scorecard metrics.
Ensures timely, accurate and complete clinical documentation to support high-quality data for physician and hospital outcome reporting.
Serves as a liaison between CDI and Coding professionals; proactively resolves discrepancies and facilitates a unified approach to clinical code assignment.
Analyzes program data and key performance indicators; creates comprehensive reports to identify trends, gaps, and opportunities for documentation improvement.
Develops and delivers education for CDI staff and physicians; provides ongoing mentorship to team members to enhance clinical knowledge and query proficiency.
Maintains effective communication with stakeholders (e.g. Quality, Revenue Cycle, Physician Leaders) to build credibility and trust.
Ensures all departmental activities comply with company policies, HIPAA regulations, and official coding guidelines.
Qualifications
Ability to prioritize and multi-task in a multifaceted environment.
Demonstrate strong organizational skills and be detail oriented.
Demonstrate ability to self-motivate, set goals, and meet deadlines.
Demonstrate mentoring and interpersonal skills.
Demonstrate excellent presentation, verbal, and written communication skills.
Ability to develop and maintain relationships with key business partners by building personal credibility and trust.
Maintains courteous and professional working relationships with employees at all levels of the organization.
Demonstrate successful leadership skills with the use of critical thinking, problem solving, and deductive reasoning required.
Specialized training in advanced computer skills with proficiency in Microsoft Word, Excel, Power Point, and Outlook e-mail required.
Additional training in Access database management, Medicare Part A and B programs, DRG assignment, and knowledge of MCC/CC preferred.
Requirements
Bachelor’s degree in nursing (BSN) or a healthcare related field.
