Lead Clinical Documentation Integrity Specialist

Role Overview

• Lead and oversee the Clinical Documentation Integrity program across participating practices, ensuring consistency, accuracy, and compliance.
• Provide leadership, guidance, and support to CDI Specialists, including education, coaching, and performance oversight.
• Develop and implement standardized CDI processes, job aids, and error‑prevention tools to optimize documentation workflows and EMR utilization.
• Educate providers and clinical staff on best practices for clinical documentation, coding accuracy, and risk adjustment.
• Conduct prospective and retrospective documentation reviews; analyze data to identify trends, gaps, and improvement opportunities.
• Collaborate with physicians, coders, population health, and practice leadership to support quality programs and value‑based care initiatives.
• Ensure compliance with applicable federal, state, and regulatory requirements related to Medicare coding and documentation.
• Lead CDI‑related projects and initiatives aligned with organizational goals and population health strategies.
• Gather provider feedback to continuously improve educational content and delivery methods.

Requirements

• Bachelor’s degree in a related field.
• Minimum of 7 years experience in Clinical Documentation Integrity (CDI), coding, or clinical documentation.
• At least 3 years of experience supporting healthcare value-based programs, including Medicare Risk (experience may run concurrently)
• At least one active coding certification required (CPC, CRC, CCS‑P, CCS‑H, RHIT, CCDS, or CDIP).
• Advanced knowledge of ICD‑10 guidelines, clinical documentation standards, and diagnostic coding.
• Knowledge of CMS quality programs, HCCs, value‑based care models, and EHR systems.
• Strong analytical, critical thinking, problem‑solving, and communication skills.
• Proficiency in Microsoft Office (Excel, Word, PowerPoint, Outlook).
• Ability to manage multiple priorities, meet deadlines, and work independently.
• Ability to travel up to 30% to participating practice offices.

Benefits

• We take great strides to ensure our employees have the resources to live well, be healthy, continue learning, develop skills, grow professionally and serve our local communities.