Clinical Documentation Improvement Lead

Job Title

Lead clinical documentation improvement initiatives focused on orthopedic and musculoskeletal specialties

Review provider documentation for completeness, specificity, medical necessity, and coding accuracy

Partner with physicians, APPs, coding teams, and operational leaders to improve documentation workflows and reduce revenue leakage

Identify trends impacting reimbursement, denials, downcoding, charge lag, and documentation deficiencies

Provide education and real-time feedback to providers regarding coding, documentation standards, payer requirements, and compliance expectations

Serve as a subject matter expert for Athena documentation workflows, claim edits, charge capture, and operational reporting

Collaborate with coding and denial management teams to resolve documentation-related reimbursement issues

Support audit readiness and compliance initiatives through routine chart reviews and documentation monitoring

Assist in the development and maintenance of documentation policies, workflows, tip sheets, and provider education materials

Analyze documentation and coding trends to support operational performance improvement and financial optimization

Monitor payer policy changes and regulatory updates impacting MSK documentation and reimbursement

Participate in cross-functional operational meetings and revenue cycle performance initiatives

Education:

Certified Professional Coder (CPC), CCS, RHIA, RHIT, or equivalent coding certification required

Experience:

Minimum 5 years of clinical documentation improvement, coding, or revenue cycle experience in orthopedic/MSK specialties required

Strong working knowledge of musculoskeletal and orthopedic procedural and diagnosis coding