Outpatient Lead CDI Specialist - Certified (Full-time, Monday - Friday)

Washington Regional Medical System•Fayetteville, AR

5d•Hybrid

About The Position

The Outpatient Lead CDI Specialist – Certified reports directly to the Vice President of Practice Transformation and serves as the direct supervisory lead for the outpatient Clinical Documentation Improvement (CDI) team. This position is responsible for providing day-to-day leadership, work direction, performance support, and operational oversight for Outpatient CDI Specialists while also performing advanced outpatient CDI review functions. The role partners closely with providers, coding, revenue cycle, quality, compliance, and practice transformation leadership to ensure accurate, complete, and compliant clinical documentation that supports appropriate coding, reimbursement, quality reporting, risk adjustment, and continuity of care across the outpatient setting.

Requirements

High school diploma or GED, required.
Active CDI, coding, or health information certification required, such as CPC, CCDS, CCDS-O, CDIP, RHIA, or RHIT.
Minimum of three years of clinical documentation improvement, coding, revenue cycle, health information management, outpatient clinical documentation review, or related healthcare experience required.
Minimum of one year of outpatient CDI or documentation integrity experience required.
Must demonstrate advanced knowledge of outpatient documentation requirements, ICD-10-CM and CPT coding guidelines, compliant query practices, risk adjustment concepts, provider education, data analysis, and performance improvement.
Must possess strong leadership, communication, critical thinking, organization, and relationship-building skills with the ability to guide a team, manage competing priorities, resolve workflow barriers, and collaborate effectively with providers, operational leaders, coding, revenue cycle, quality, and compliance stakeholders.

Nice To Haves

Minimum of associate’s degree in a healthcare or business-related field, preferred.
Graduate of an accredited nursing program, preferred.
CCDS-O or other outpatient CDI-focused certification preferred.
RN or LPN licensure preferred when supported by clinical background and experience.
Prior lead, supervisory, preceptor, training, audit, or team coordination experience strongly preferred.

Responsibilities

Conduct and oversee comprehensive reviews of outpatient medical records to identify documentation opportunities, including missing diagnoses, specificity, severity of illness, risk adjustment support, procedure documentation, treatment details, and appropriate linkage between clinical findings and coded data.
Educate, coach, and collaborate with outpatient providers, clinic leaders, coding staff, and CDI team members regarding documentation requirements, best practices, compliant query processes, and opportunities to improve the accuracy and completeness of clinical documentation.
Provide direct supervision and daily leadership for Outpatient CDI Specialists, including workload assignment, prioritization of reviews, monitoring of productivity and quality expectations, coaching, mentoring, and support for individual and team performance.
Serve as the primary escalation resource for outpatient CDI workflow questions, provider documentation concerns, query appropriateness, outpatient coding documentation opportunities, and team process standardization.
Support hiring, onboarding, training, competency assessment, performance feedback, and corrective action recommendations for assigned Outpatient CDI Specialists in collaboration with the Vice President of Practice Transformation and Human Resources.
Analyze outpatient CDI program data, including documentation quality, provider query trends, productivity, impact measures, denial trends, risk adjustment opportunities, and team performance metrics; prepare reports and present findings, recommendations, and improvement opportunities to practice transformation leadership.
Maintain current knowledge of outpatient CDI principles, ICD-10-CM, CPT, HCPCS, HCC/risk adjustment concepts, payer documentation requirements, Medicare regulations, compliance expectations, and applicable industry standards.
Lead outpatient CDI program initiatives, including workflow design, education development, process improvement, audit readiness, documentation standardization, and implementation of strategies that improve provider engagement, documentation integrity, and outpatient revenue cycle outcomes.