Lead Clinical Documentation Improvement - Hybrid

Community Health Systems • Laredo, TX

4d • Hybrid

About The Position

The Clinical Documentation Improvement (CDI) Lead provides advanced support for clinical documentation improvement activities across assigned facilities, helping ensure 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 on documentation improvement initiatives. Responsibilities include complex documentation reviews, provider education, mentoring and operational support for CDI staff, monitoring performance indicators, and contributing to staff training and professional development. The role also supports audits, reporting, compliance reviews, and the use of CDI tools and systems in accordance with organizational standards.

This hybrid role is in the Laredo, Texas area. It is fully onsite for the first six months. After six months, 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 to support CDI operations, education, and performance improvement initiatives.

Requirements

• Associate degree in Nursing or a comparable clinical field (e.g., International MD).
• 4–6 years of acute care hospital nursing experience, such as medical/surgical unit or intensive care experience.
• 4–6 years of experience in clinical documentation improvement.
• 1–3 years of provider or physician education experience.
• RN state licensure and/or compact state licensure, or a comparable clinical license (e.g., 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.
• Demonstrated 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 accurate clinical 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.
• Facilitate provider education and feedback regarding 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, continuing education, and professional development activities for CDI staff.
• Ensure appropriate use of CDI tools, query templates, and documentation systems in alignment with organizational standards.
• Maintain knowledge of coding guidelines, regulatory requirements, and documentation standards, and communicate updates to stakeholders.
• Participate in audits, reporting activities, 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 with monitoring staff performance and supporting performance management processes.
• Perform other duties as assigned.
• Maintain regular and reliable attendance and comply with all policies and standards.

Benefits

• Competitive compensation
• Paid time off for vacations, holidays, and illness
• Comprehensive health insurance, including medical, dental, vision, and prescription coverage
• 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