What are the responsibilities and job description for the Lead Clinical Documentation Improvement (CDI) position at HVHS Brand?
Department: Clinical Documentation Improvement (CDI)
Work Hours: Full Time. Monday – Friday, primarily daylight. Occasional off hours support as needed.
Basic Function:
The Lead of Clinical Documentation Improvement (CDI) assists in providing strategic and operational leadership for the Health System’s clinical documentation program. This role assists in ensuring the accuracy, integrity, and compliance of clinical data, optimizes reimbursement, and drives initiatives to enhance documentation operations. The lead helps develop and implement departmental strategies, oversee workflow and resource allocation, and drive process improvement. Collaborates with physicians, clinical staff, coding professionals, and health information teams to improve documentation quality, maintain regulatory compliance and support performance improvement initiatives and quality improvement goals.
Qualifications:
Required:
• Bachelor’s degree in Nursing, Health Information Management, or related field.
• Minimum 5 years of experience in acute care, coding, clinical documentation, or health information management or leadership/supervisory experience in any of the noted areas.
• Knowledge of ICD-10, CPT, MS-DRG/APR-DRG, APC, and coding compliance standards.
• Strong strategic planning, analytical, and problem-solving skills with ability to influence organizational priorities.
• Proficiency in Microsoft Office (Word, Excel, PowerPoint) and electronic medical records.
• Effective communication skills with physicians, clinical staff, and coding teams
Preferred:
• Certified Clinical Documentation Specialist (CCDS).
• Clinical and coding experience with knowledge of Medicare Part A and Part B.
• Knowledge of Core Measures, Patient Safety Indicators, and regulatory guidelines (TJC, CMS, PA Department of Health).