CDI Specialist-Lead
About The Position
The CDI Specialist–Lead is a CDI-certified coding professional responsible for designing, implementing, and sustaining the organization’s Clinical Documentation Improvement (CDI) and Data-Driven Integrity (DDI) program. This role ensures accurate, complete, and compliant clinical documentation and coding practices across the organization. The CDI Specialist–Lead establishes documentation standards, develops and delivers provider education, monitors key DDI metrics, and partners with clinical and coding teams to enhance documentation quality. This position plays a critical role in improving capture of primary diagnoses, supporting accurate reimbursement, reducing administrative burden on providers, and maintaining high standards of regulatory compliance and data integrity.
Requirements
- Current CDI certification (CDIP, CCDS, or equivalent).
- Strong knowledge of ICD-10-CM, CPT, and HCPCS coding guidelines.
- In-depth understanding of clinical documentation improvement principles and best practices.
- Familiarity with state and federal regulations, payer requirements, and healthcare compliance standards.
- Demonstrated ability to analyze clinical documentation and coding trends.
- Excellent written and verbal communication skills.
- Strong collaboration and stakeholder engagement skills.
- High School Diploma or equivalent required.
Nice To Haves
- Experience in a clinical coding role within a behavioral health or pediatric healthcare setting.
- Experience developing documentation standards or provider education programs.
- Experience implementing CDI programs or leading data quality initiatives.
- Experience monitoring and reporting documentation quality metrics.
- Proficiency with electronic health record (EHR) systems and coding software.
- Two-year Health Information Management (HIM) college-level program preferred.
- Certified Professional Coder (CPC)
- Certified Coding Specialist (CCS)
- Other relevant coding credentials
- Employees authorized to use their personal vehicle for agency business must maintain: A valid driver’s license in their state of residence An acceptable driving record per agency standards Current personal automobile insurance coverage
Responsibilities
- Lead the development, implementation, and ongoing management of the CDI and DDI program.
- Establish and maintain clinical documentation standards aligned with ICD-10-CM, CPT, HCPCS, and payer guidelines.
- Monitor and analyze documentation and coding trends; identify opportunities for improvement.
- Develop and deliver educational initiatives and training materials for providers and clinical staff.
- Conduct documentation reviews to ensure accuracy, completeness, and regulatory compliance.
- Track and report key CDI/DDI metrics; recommend data-driven improvements.
- Collaborate with coding, compliance, clinical leadership, and revenue cycle teams.
- Support accurate capture of primary diagnoses and appropriate risk adjustment.
- Ensure adherence to state and federal regulations, payer requirements, and healthcare compliance standards.
- Reduce administrative burden on providers through workflow optimization and documentation clarity.
- Serve as subject matter expert for CDI-related initiatives and audits.
Benefits
- Full-time 40 hours per week schedule.
- Comprehensive employer-paid healthcare benefits for eligible employees
- 401k with 6% match
- Generous vacation and sick leave
- A supportive team environment dedicated to equity, compassion, and high-quality care.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
High school or GED
