Lead Clinical Documentation Improvement Specialist; REMOTE

Lead Clinical Documentation Improvement Specialist (REMOTE)

Join to apply for the Lead Clinical Documentation Improvement Specialist (REMOTE) role at The Ohio State University Wexner Medical Center

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.

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 the 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.

• Perform concurrent and retrospective 1st line and 2nd level reviews to identify opportunities to improve medical record documentation quality.
• Conduct audits to assess query compliance, coding accuracy, and provider education opportunities.
• Develop and deliver education to ensure competency and compliance across CDI, coding, quality, and clinical leadership teams.
• Serve as a liaison between CDI, coding, quality, compliance, clinical providers, and organizational leadership.
• Collaborate with CDI Manager to develop and manage education curriculum for onboarding and ongoing CDI education.
• Participate in interdisciplinary work groups as a subject matter expert to achieve outcomes.

• Bachelor’s degree in nursing;
  Registered Nurse. 6 years of relevant experience required; 6-10 years 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, word processing, and electronic spreadsheets

• 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

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Thank you for your interest in working at Ohio State.

The university is an equal opportunity employer, including veterans and disability.

• Mid-Senior level

• Full-time

• Health Care Provider

• Hospitals and Health Care