Lead Clinical Documentation Improvement - Hybrid

Community Health Systems Professional Services Corporation • Franklin, TN

5d • Hybrid

About The Position

The Clinical Documentation Improvement (CDI) Lead provides advanced support for clinical documentation improvement activities across assigned facilities, ensuring clinical documentation is accurate, complete, and reflects patient severity, acuity, and complexity of care. The role promotes compliant documentation practices that support accurate coding, reimbursement, regulatory compliance, and quality outcomes.

The CDI Lead collaborates with providers, coding teams, clinical leadership, and interdisciplinary stakeholders. The role also supports documentation improvement initiatives, provider education, staff mentoring and training, and organizational CDI goals. The position is hybrid in the Laredo, Texas area: the first six months are fully onsite, after which employees meeting performance metrics may transition to a schedule of two days in the office and three days remote. Travel to assigned facilities is required.

Requirements

• Associate Degree in Nursing or a comparable clinical field, such as an international MD.
• 4–6 years of acute care hospital nursing experience, such as medical/surgical or intensive care.
• 4–6 years of clinical documentation improvement experience.
• 1–3 years of provider or physician education experience.
• RN state licensure and/or compact state licensure, or a comparable clinical license such as an international MD.
• Valid, in-state driver license.
• Strong knowledge of disease processes, clinical care standards, and medical terminology.
• Knowledge of ICD-10-CM/PCS coding principles, MS-DRG/APR-DRG methodologies, and inpatient prospective payment systems.
• Strong verbal and written communication skills, including the ability to educate and provide feedback to providers and interdisciplinary teams.
• Strong critical thinking, prioritization, and problem-solving skills.
• Proficiency with CDI software, encoder tools, electronic medical records, and standard office software applications.
• Ability to mentor and support the professional development of CDI staff.
• Ability to work independently, manage competing priorities, and meet deadlines.
• Professionalism, collaboration, and leadership in interdisciplinary healthcare environments.

Nice To Haves

• Bachelor's Degree in Nursing, Health Information Management, or a related field.
• Experience in ICU/critical care, case management, utilization review, quality, or inpatient coding.
• CCS-Certified Coding Specialist, ICD-10 certification, or trainer designation.
• Certified Clinical Documentation Specialist (CCDS).
• RHIT - Registered Health Information Technician.
• RHIA - Registered Health Information Administrator.
• CDIP - Clinical Documentation Improvement Professional.
• Certified Coder-AHIMA or AAPC.

Responsibilities

• Lead and support facility-level CDI activities to promote documentation reflecting patient severity, acuity, and complexity of care.
• Perform complex clinical documentation reviews and provide guidance, mentoring, and operational support to CDI team members.
• Provide provider education and feedback on documentation opportunities, query practices, and CDI initiatives.
• Collaborate with coding, HIM, quality, care management, and clinical teams to support accurate data reporting, reimbursement, and quality outcomes.
• Monitor and report CDI key performance indicators, trends, and outcomes to facility and corporate stakeholders.
• Support onboarding, training, and continuing education for CDI staff and contribute to professional development initiatives.
• Ensure appropriate use of CDI tools, query templates, and documentation systems in accordance with organizational standards.
• Maintain knowledge of coding guidelines, regulatory requirements, and documentation standards, and communicate updates to stakeholders.
• Participate in audits, reporting, and compliance reviews related to CDI operations.
• Attend facility meetings, interdisciplinary rounds, and operational discussions as assigned.
• Travel to assigned facilities to support CDI operations, education, and performance improvement initiatives.
• Assist leadership in monitoring staff performance and supporting performance management processes.
• Perform other duties as assigned.
• Maintain regular and reliable attendance.
• Comply with all policies and standards.

Benefits

• Competitive compensation
• Paid time off for vacations, holidays, and illness
• Comprehensive health insurance (medical, dental, vision, prescription)
• 401(k) retirement savings plan
• Education support and student loan assistance
• Life and disability insurance
• Flexible spending account

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: Associate degree