Lead Clinical Documentation Improvement - Hybrid

Community Health Systems • Tucson, AZ

4d • Hybrid

About The Position

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

The CDI Lead collaborates with providers, coding teams, clinical leadership, and interdisciplinary stakeholders. The position includes complex documentation reviews, provider education, mentoring and operational support for CDI team members, monitoring performance indicators, supporting staff training, and contributing to CDI initiatives and organizational goals. The role is hybrid in the Tucson, Arizona area: the first six months are fully onsite; 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.

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 or intensive care.
• 4–6 years of experience in clinical documentation improvement.
• 1–3 years of provider or physician education experience.
• Registered Nurse 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, or Certified Clinical Documentation Specialist (CCDS).
• RHIT-Registered Health Information Technician or RHIA-Registered Health Information Administrator.
• CDIP-Clinical Documentation Improvement Professional or 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 current 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