Lead Clinical Documentation Improvement

This role is hybrid in the Laredo, Texas area.

For the first six months, this role is fully onsite. After six months, employees meeting performance metrics have the option to transition to a hybrid schedule of two days in the office and three days remote.

Our Benefits:

• Competitive compensation
• Paid time off for vacations, holidays, and illness
• Comprehensive health insurance (medical, dental, vision, prescription)
• 401(k) retirement savings plan
• Education support and student loan assistance
• Life and disability insurance
• Flexible spending account

As a Clinical Documentation Improvement Lead at Community Health Systems (CHS) – Shared Business Operations, you’ll play a vital role in supporting our purpose to help people get well and live healthier by providing safe, quality healthcare, building enduring relationships with our patients, and providing value for the people and communities we serve. 

Job Summary

The Clinical Documentation Improvement (CDI), Lead provides advanced support for clinical documentation improvement activities across assigned facilities to ensure the accuracy, completeness, and integrity of clinical documentation. This role supports compliant documentation practices that reflect patient severity, acuity, and quality outcomes while promoting accurate coding, reimbursement, and regulatory compliance. The CDI, Lead collaborates with providers, coding teams, clinical leadership, and interdisciplinary stakeholders to support documentation improvement initiatives, provide education and mentoring, and drive achievement of organizational CDI goals.

Essential Functions

• Leads and supports facility-level CDI activities to promote accurate clinical documentation reflecting patient severity, acuity, and complexity of care.
• Performs complex clinical documentation reviews and provides guidance, mentoring, and operational support to CDI team members.
• Facilitates provider education and feedback regarding documentation opportunities, query practices, and clinical documentation improvement initiatives.
• Collaborates with coding, HIM, quality, care management, and clinical teams to support accurate data reporting, reimbursement, and quality outcomes.
• Monitors and reports CDI key performance indicators, trends, and outcomes to facility and corporate stakeholders.
• Supports onboarding, training, and continuing education activities for CDI staff and contributes to professional development initiatives.
• Ensures appropriate utilization of CDI tools, query templates, and documentation systems in alignment with organizational standards.
• Maintains current knowledge of coding guidelines, regulatory requirements, and documentation standards and communicates updates to stakeholders.
• Participates in audits, reporting activities, and compliance reviews related to CDI operations.
• Attends facility meetings, interdisciplinary rounds, and operational discussions as assigned.
• Travels to assigned facilities to support CDI operations, education, and performance improvement initiatives.
• Assists leadership with monitoring staff performance and supporting performance management processes.
• Performs other duties as assigned.
• Maintains regular and reliable attendance.
• Complies with all policies and standards.

Requirements:

• Associate Degree in Nursing, or comparable clinical field (e.g., International MD) required
• 4-6 years of acute care hospital nursing experience (e.g. medical/surgical unit, intensive care) required
• 4-6 years of experience in clinical documentation improvement required
• 1-3 years of provider or physician education experience required
• RN - Registered Nurse - State Licensure and/or Compact State Licensure or comparable clinical license (e.g., International MD) required

Preferences:

• Bachelor's Degree in Nursing, Health Information Management, or a related field preferred
• Experience in ICU/Critical Care, case management, utilization review, quality, or inpatient coding preferred

Knowledge, Skills and Abilities

• Strong knowledge of disease processes, clinical care standards, and medical terminology.
• Knowledge of ICD-10-CM/PCS coding principles, MS-DRG/APR-DRG methodologies, and inpatient prospective payment systems.
• Strong verbal and written communication skills, including the ability to provide education and feedback to providers and interdisciplinary teams.
• Strong critical thinking, prioritization, and problem-solving skills.
• Proficiency with CDI software, encoder tools, electronic medical records, and standard office software applications.
• Ability to mentor and support professional development of CDI staff.
• Ability to work independently, manage competing priorities, and meet deadlines.
• Demonstrated professionalism, collaboration, and leadership in interdisciplinary healthcare environments.

Licenses and Certifications

• DL NUMBER - Driver License, Valid and in State required
• CCS-Certified Coding Specialist or ICD-10 certification or trainer designation preferred or
• Certified Clinical Documentation Specialist (CCDS) preferred
• RHIT - Registered Health Information Technician preferred or
• RHIA - Registered Health Information Administrator preferred
• CDIP - Clinical Documentation Improvement Professional preferred or
• Certified Coder-AHIMA or AAPC preferred