Remote CDI Lead: Elevate Clinical Documentation

Thompson Health; City of Canandaigua (NY); Remote; USD 55,000 - 66,000; Full time

Job summary

UR Medicine Thompson Health in Canandaigua, NY, seeks a Lead Clinical Documentation Specialist (RN) to enhance documentation quality and reimbursement. Remote role with occasional onsite orientation and meetings, with strong leadership and coding expertise expected.

The ideal candidate has a minimum 5 years inpatient RN experience and will oversee CDI practices, coordinate education, and drive program improvements while ensuring HIPAA compliance.

Qualifications

• Licensed RN with minimum of 5 years inpatient clinical experience.
• CDS or CDIP certification required within two years of starting the role.
• Expertise in clinical documentation concepts and compliant documentation practices.

Responsibilities

• Performs extensive medical record review through CDI software integrated with the EMR.
• Leads CDI team and coordinates clinical documentation improvement practices.
• Oversee training and education for providers, nurses and CDI staff.
• Actively participate in team meetings to develop improvement efforts and education regarding the Clinical Documentation Management Program (CDMP)

Skills

CDI Leadership

Clinical Documentation

HIPAA Compliance

Physician Queries

Data Analysis

Education & Training

Team Leadership

EHR Proficiency

Education

AAS

BSN preferred

Tools

Microsoft Office

Job description

UR Medicine Thompson Health in Canandaigua, NY, seeks a Lead Clinical Documentation Specialist (RN) to enhance documentation quality and reimbursement. Remote role with occasional onsite orientation and meetings, with strong leadership and coding expertise expected.

The ideal candidate has a minimum 5 years inpatient RN experience and will oversee CDI practices, coordinate education, and drive program improvements while ensuring HIPAA compliance.