Lead Clinical Documentation Improvement Specialist

Scope of Position

The Clinical Documentation Improvement Analyst 4 (CDI Analyst 4) is responsible for performing concurrent and retrospective 1st line and 2nd level reviews to identify opportunities for improving the quality of medical record documentation. The CDI Analyst 4 completes audits to assess query compliance, coding accuracy, and provider education opportunities. The CDI Analyst 4 develops and provides education to ensure competency and compliance, and functions as a liaison between the CDI department, coding, quality, compliance, clinical providers and organizational leadership.

Position Summary

This position supports initiatives to improve healthcare provider documentation integrity to ensure accurate medical coding within the Ohio State University Health System. The CDI Analyst 4 follows JCAHO, CMS, third party payor documentation guidelines, and the official guidelines for assigning ICD-10 working diagnosis and procedure codes in efforts to continually improve the quality of medical record documentation. The CDI Analyst 4 works closely with CDI Manager to develop, present, and manage education curriculum for CDI onboarding, and continued education for CDI specialists, providers and physician advisors. The CDI Analyst 4 completes second level review for quality measures, clinical validation, and outcomes improvement. CDI Analyst 4 participates in interdisciplinary work groups as subject matter expert to achieve desired outcomes.

Minimum Qualifications

For Hire :

Bachelors degree in nursing. Registered Nurse. 6 years of relevant experience required. 6-10 years of relevant experience preferred.

Active RN license

CCDS (Certified Clinical Documentation Specialist or CDIP (Certified Documentation Improvement Practitioner) certification

Knowledge and experience in medical information, computer applications, coding applications, work processing, and electronic spreadsheets

Ongoing :

Maintain RN licensure in good standing

Maintain CCDS or CDIP certification in good standing

Experience in Clinical Documentation Integrity Auditing / Education

Proficiency in ICD-10-CM / PCS coding and AHA Coding Clinic

Excellent communication and team collaboration skills

Ability to work independently and manage multiple tasks effectively

Familiarity with payer compliance and quality metrics

Active involvement in quality assurance and process improvement initiatives

Ensuring compliance with all relevant healthcare regulations and standards

Career Roadmap :

FUNCTION : Health Information Management

SUB-FUNCTION : Clinical Documentation Improvement

CAREER BAND : Individual Contributor - Specialized

CAREER LEVEL : S4

80% remote