Role Description
The CDI Specialist–Lead is a CDI-certified coding professional responsible for designing, implementing, and sustaining the organization’s Clinical Documentation Improvement (CDI) and Data-Driven Integrity (DDI) program. This role ensures accurate, complete, and compliant clinical documentation and coding practices across the organization.
• Lead the development, implementation, and ongoing management of the CDI and DDI program.
• Establish and maintain clinical documentation standards aligned with ICD-10-CM, CPT, HCPCS, and payer guidelines.
• Monitor and analyze documentation and coding trends; identify opportunities for improvement.
• Develop and deliver educational initiatives and training materials for providers and clinical staff.
• Conduct documentation reviews to ensure accuracy, completeness, and regulatory compliance.
• Track and report key CDI/DDI metrics; recommend data-driven improvements.
• Collaborate with coding, compliance, clinical leadership, and revenue cycle teams.
• Support accurate capture of primary diagnoses and appropriate risk adjustment.
• Ensure adherence to state and federal regulations, payer requirements, and healthcare compliance standards.
• Reduce administrative burden on providers through workflow optimization and documentation clarity.
• Serve as subject matter expert for CDI-related initiatives and audits.
Qualifications
• Current CDI certification (CDIP, CCDS, or equivalent).
• Strong knowledge of ICD-10-CM, CPT, and HCPCS coding guidelines.
• In-depth understanding of clinical documentation improvement principles and best practices.
• Familiarity with state and federal regulations, payer requirements, and healthcare compliance standards.
• Demonstrated ability to analyze clinical documentation and coding trends.
• Excellent written and verbal communication skills.
• Strong collaboration and stakeholder engagement skills.
• High School Diploma or equivalent required.
• Two-year Health Information Management (HIM) college-level program preferred.
Requirements
• Experience in a clinical coding role within a behavioral health or pediatric healthcare setting.
• Experience developing documentation standards or provider education programs.
• Experience implementing CDI programs or leading data quality initiatives.
• Experience monitoring and reporting documentation quality metrics.
• Proficiency with electronic health record (EHR) systems and coding software.
Certificates, Licenses & Registrations
• Required: CDI certification (CDIP, CCDS, or equivalent).
• Preferred: Certified Professional Coder (CPC)
• Preferred: Certified Coding Specialist (CCS)
• Other relevant coding credentials
Benefits
• Full-time 40 hours per week schedule.
• Comprehensive employer-paid healthcare benefits for eligible employees.
• 401k with 6% match.
• Generous vacation and sick leave.
• A supportive team environment dedicated to equity, compassion, and high-quality care.