- Laredo, Texas, United States
- Hybrid
- Full-time · Lead
- 4–6 years
The Clinical Documentation Improvement (CDI), Lead provides advanced support for clinical documentation improvement activities across assigned facilities to ensure the accuracy, completeness, and integrity of clinical documentation. This role supports compliant documentation practices that reflect patient severity, acuity, and quality outcomes while promoting accurate coding, reimbursement, and regulatory compliance.
Responsibilities
- Leads and supports facility-level CDI activities to promote accurate clinical documentation reflecting patient severity, acuity, and complexity of care.
- Performs complex clinical documentation reviews and provides guidance, mentoring, and operational support to CDI team members.
- Facilitates provider education and feedback regarding documentation opportunities, query practices, and clinical documentation improvement initiatives.
- Collaborates with coding, HIM, quality, care management, and clinical teams to support accurate data reporting, reimbursement, and quality outcomes.
- Monitors and reports CDI key performance indicators, trends, and outcomes to facility and corporate stakeholders.
Requirements
- Associate Degree in Nursing
- International MD
- RN - Registered Nurse - State Licensure and/or Compact State Licensure or comparable clinical license
- Nice to have: Bachelor's Degree in Nursing
- Nice to have: Health Information Management