RN, Clinical Documentation Integrity Specialist Lead | Clinical Documentation Integrity (CDI)

UF Health • Jacksonville, FL

11h • Remote

About The Position

This role focuses on leading initiatives to ensure the accuracy, completeness, and integrity of clinical documentation. The specialist will review clinical records to identify documentation gaps and collaborate with providers to improve quality and compliance. They will develop and implement improvement strategies, education, and training programs for clinical staff, monitor regulatory changes, and lead audits and quality assurance activities. This position also serves as a liaison between clinical teams and coding specialists to ensure alignment and accuracy, analyzes findings, reports trends, and recommends corrective actions. The goal is to promote best practices in clinical documentation to support patient care, compliance, and revenue integrity.

Requirements

• Associate’s or Bachelor’s degree in Nursing required
• Active RN license required (if applicable based on education pathway)
• 5+ years of experience in Clinical Documentation Improvement (CDI), including leadership or lead-level responsibilities
• Strong expertise in regulatory compliance, audit management, and clinical documentation standards
• Proven ability to develop and implement training programs and process improvement initiatives
• Demonstrated success leading cross-functional teams and collaborating with clinical and coding professionals
• Experience monitoring documentation quality, analyzing trends, and reporting outcomes
• Ability to work independently with minimal supervision
• Strong written and verbal communication skills
• Ability to generate clear, concise management reports, including audit results
• Ability to meet deadlines and adapt to frequent regulatory changes
• Strong ability to maintain positive relationships with internal and external stakeholders
• Self-starter with strong initiative and accountability

Nice To Haves

• Bachelor’s degree preferred
• International Medical Graduate (IMG) with a Medical School Diploma may be considered in lieu of nursing degree
• Certified Clinical Documentation Specialist (CCDS), Certified Documentation Integrity Practitioner (CDIP), or equivalent CDI certification preferred

Responsibilities

• Lead initiatives to ensure the accuracy, completeness, and integrity of clinical documentation
• Review clinical records to identify documentation gaps and collaborate with providers to improve quality and compliance
• Develop and implement improvement strategies, education, and training programs for clinical staff
• Monitor regulatory changes and lead audits and quality assurance activities
• Serve as a liaison between clinical teams and coding specialists to ensure alignment and accuracy
• Analyze findings and report trends, recommending corrective actions to uphold documentation standards
• Promote best practices in clinical documentation to support patient care, compliance, and revenue integrity

What This Job Offers

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