Clinical Documentation Improvement Lead

The CORE Institute; Phoenix (AZ); On-site; USD 70,000 - 90,000; Full time

Job summary

The CORE Institute is seeking a professional to lead clinical documentation improvement initiatives in orthopedic care. This role requires a Certified Professional Coder and a minimum of five years of relevant experience. The candidate will work closely with various healthcare teams to enhance documentation accuracy and compliance.

Responsibilities include analyzing documentation standards, providing education to providers, and participating in performance improvement initiatives. The ideal candidate should have a strong understanding of orthopedic coding and reimbursement processes.

Qualifications

• Minimum 5 years of clinical documentation improvement in orthopedic/MSK specialties.
• Strong working knowledge of orthopedic procedural and diagnosis coding.

Responsibilities

• Lead clinical documentation improvement initiatives in orthopedic specialties.
• Review provider documentation for accuracy and compliance.
• Provide feedback to improve documentation workflows and reduce revenue leakage.
• Support audit readiness through routine chart reviews.

Skills

Clinical documentation improvement

Coding accuracy

Communication skills

Education

Certified Professional Coder (CPC) or equivalent

Job description

ESSENTIAL FUNCTIONS

• Lead clinical documentation improvement initiatives focused on orthopedic and musculoskeletal specialties
• Review provider documentation for completeness, specificity, medical necessity, and coding accuracy
• Partner with physicians, APPs, coding teams, and operational leaders to improve documentation workflows and reduce revenue leakage
• Identify trends impacting reimbursement, denials, downcoding, charge lag, and documentation deficiencies
• Provide education and real-time feedback to providers regarding coding, documentation standards, payer requirements, and compliance expectations
• Serve as a subject matter expert for Athena documentation workflows, claim edits, charge capture, and operational reporting
• Collaborate with coding and denial management teams to resolve documentation-related reimbursement issues
• Support audit readiness and compliance initiatives through routine chart reviews and documentation monitoring
• Assist in the development and maintenance of documentation policies, workflows, tip sheets, and provider education materials
• Analyze documentation and coding trends to support operational performance improvement and financial optimization
• Monitor payer policy changes and regulatory updates impacting MSK documentation and reimbursement
• Participate in cross-functional operational meetings and revenue cycle performance initiatives

EDUCATION

• Certified Professional Coder (CPC), CCS, RHIA, RHIT, or equivalent coding certification required

EXPERIENCE

• Minimum 5 years of clinical documentation improvement, coding, or revenue cycle experience in orthopedic/MSK specialties required
• Strong working knowledge of musculoskeletal and orthopedic procedural and diagnosis coding

Equal Opportunity Employer
This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.