CDI Program Lead – Clinical Documentation

Cape Fear Valley Health; United States; On-site; USD 85,000 - 110,000; Full time

Job summary

Cape Fear Valley Health in Fayetteville, NC, seeks a CDI Specialist to monitor and coordinate the CDI program across inpatient records. You will educate medical staff and serve as a preceptor for new hires, driving improvements in documentation to support appropriate reimbursement for DRG-based payors.

Responsibilities include leading daily CDI workflows, reviewing performance, and coordinating education for physicians and other care providers.

Qualifications

• Associate degree in Nursing required.
• CCDS and/or CDIP certification required or must complete within 1 year of hire.
• 5 years of clinical experience in inpatient hospital setting required with at least 1 year of critical care experience.
• 3 years of ICD-10 inpatient CDI reviewer experience required.

Responsibilities

• Oversee and coordinate the CDS specialist processes for daily workflow efficiency.
• Serve as new hire preceptor and provide education and training in train-the-trainer methodology.
• Review performance reports and track the CDMP program impact across providers and departments.
• Identify educational needs for medical staff through CDIS reviews and program monitoring.
• Coordinate ongoing education for physicians and mid-level providers on documentation improvement opportunities.
• Train internal customers on clinical documentation opportunities, coding, reimbursement issues, and performance improvement methodologies.
• Identify principal diagnoses and CCs to reflect severity of illness (SOI/ROM) per government regulations.
• Facilitate modifications to clinical documentation to support DRG-based reimbursement.
• Consult with physicians to clarify information and educate on documentation significance.
• Review charts with Senior Coding Specialist/Director CDIP and Coding staff as needed.
• Other duties as assigned.

Skills

CDI knowledge

Communication skills

Analytical thinking

Teamwork

Problem solving

Education

Associate's degree in Nursing

Nursing licensure in NC

Bachelor's degree in Nursing preferred

Job description

Cape Fear Valley Health in Fayetteville, NC, seeks a CDI Specialist to monitor and coordinate the CDI program across inpatient records. You will educate medical staff and serve as a preceptor for new hires, driving improvements in documentation to support appropriate reimbursement for DRG-based payors.

Responsibilities include leading daily CDI workflows, reviewing performance, and coordinating education for physicians and other care providers.