Clinical Documentation Integrity Lead

Master’s

• 12+ years of CDI or related clinical coding experience, with 4+ years in management
• CDI certification (CCDS, CDIP) or AHIMA / AAPC credential is a strong plus
• Strong stakeholder engagement, coaching, and changing management skills

12+ years of experience in Clinical Documentation Integrity professionals with clinical expertise, inpatient hospital coding, or inpatient clinical documentation integrity / improvement experience

• Inpatient Clinical Documentation Integrity / Improvement experience
• Inpatient hospital clinical critical care experience (examples include hands on patient experience in the Emergency Department, Critical Care, and Med / Surg units)
• Inpatient hospital coding, including the MS-DRG structure
• Inpatient CDI experience (not HCC or physician office-based)
• Clinical knowledge (e.G., sepsis, pneumonia, CHF, respiratory failure)
• Strong understanding of DRG assignment and optimization
• Experience reviewing inpatient medical records
• Familiarity with ICD-10-CM / PCS coding
• Knowledge of clinical indicators, query writing
• Ability to identify inpatient physician documentation gaps
• Understanding of principal diagnosis selection
• Familiarity with MS-DRG

INPATIENT CDI EXPERIENCE

• Inpatient CDI experience (not HCC or physician office-based)

INPATIENT CODING EXPERIENCE

Understanding of :

• o MS-DRG assignment and optimization
• o ICD-10-CM / PCS coding
• o Principal diagnosis selection
• Experience reviewing inpatient medical records

CLINICAL KNOWLEDGE

• Clinical knowledge (e.G., sepsis, pneumonia, CHF, respiratory failure)
• Knowledge of clinical indicators, query writing.
• Ability to identify inpatient physician documentation gaps

CCDS / CDIP or AHIMA / AAPC equivalent credential

Proficiency in DRG optimization, clinical documentation standards, and mentoring

Excellent leadership, interpersonal, and decision-making skills