RN Clinical Documentation Integrity Lead

4 weeks ago


St Petersburg FL United States Networks Connect Professional Staffing Full time

Clinical Documentation Integrity Lead (CDI Lead)


Job Description:

Networks Connect is conducting a search for a local prominent healthcare system for someone to join their dynamic healthcare team as a Clinical Documentation Integrity Lead Leverage your expertise in clinical documentation, compliance, and healthcare coding to spearhead our CDI program. This role is crucial in enhancing the accuracy, quality, and completeness of medical record documentation.


Key Responsibilities:

  • Lead day-to-day operations of the Clinical Documentation Integrity program.
  • Collaborate with CDI Specialists, department heads, and healthcare providers (including Physicians, Advanced Practice Professionals, and Medical Residents) to enhance medical record documentation.
  • Conduct thorough audit investigations, educational initiatives, and data analysis to ensure documentation quality.
  • Work closely with medical coders and healthcare staff to ensure accurate coding and appropriate charge capture.
  • Perform pre-bill compliance audits, adhering to coding guidelines and regulatory requirements.
  • Proactively identify and resolve issues impacting data quality and reimbursement accuracy.


Required Qualifications:

  • At least four years of experience as a Clinical Documentation Integrity Specialist.
  • Bachelor’s degree in Nursing (BSN) or Associate of Science in Nursing (ASN) with two years of relevant clinical experience.
  • Active Florida RN or MD license.
  • Obtain CDIP or CCDS certification within one year.


Preferred Qualifications:

  • Experience in Clinical Documentation Integrity Auditing/Education.
  • Proficiency in ICD-10-CM 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.


Key Job Standards:

  • Comprehensive management of daily CDI operations, including chart audits and query resolutions.
  • Development of CDI educational programs for staff and physicians.
  • Advanced use of CDI software and maintaining data integrity.
  • Active involvement in quality assurance and process improvement initiatives.
  • Ensuring compliance with all relevant healthcare regulations and standards.



  • Washington, DC, United States MEDSTAR HEALTH Full time

    General Summary of PositionThe Clinical Documentation Integrity (CDI) Auditor is responsible for providing expert second level review to ensure the quality and integrity of medical records. Responsibility includes validating ICD-10-CM/PCS codes by examining medical record documentation of clinical findings, care rendered, and the assignment of present on...


  • Washington, DC, United States MEDSTAR HEALTH Full time

    General Summary of PositionThe Clinical Documentation Integrity (CDI) Auditor is responsible for providing expert second level review to ensure the quality and integrity of medical records. Responsibility includes validating ICD-10-CM/PCS codes by examining medical record documentation of clinical findings, care rendered, and the assignment of present on...


  • Tyler, TX, United States Christus Health Full time

    DescriptionSummary: The Clinical Documentation Specialist (CDS) position is responsible for facilitating improvement in the overall quality and completeness of the medical record documentation. The CDS will provide support and expertise through comprehensive assessment and review of inpatient medical records. The CDS will facilitate accurate DRG assignment...


  • Jacksonville, FL, United States Saint Vincent's Medical Center Riverside Full time

    Clinical Documentation Improvement RN SpecialistDetails * Department: Total Quality Management * Schedule: Full Time, Day Shift, Monday - Friday, 8am - 4:30pm * Hospital: Ascension St. Vincent's Riverside * Location: Jacksonville, FL This is a remote position. Benefits Paid time off (PTO) Various health insurance options & wellness plans Retirement...


  • Orlando, FL, United States Orlando Health Full time

    CDI Specialist III Registered Nurse - Clinical Documentation - Orlando HealthPosition Summary Provides concurrent review of the clinical documentation in the medical record; review the medical record with a clinical lens to identify any missing or understated diagnoses or procedures. This is a hybrid role Responsibilities Conducts initial and follow-up...


  • , FL, United States Ascension Health Full time

    Details* Department: Total Quality Management* Schedule: Full Time, Day Shift, Monday - Friday, 8am - 4:30pm* Hospital: Ascension St. Vincent's Riverside* Location: Jacksonville, FLThis is a remote position.BenefitsPaid time off (PTO)Various health insurance options & wellness plansRetirement benefits including employer match plansLong-term & short-term...


  • , WA, United States APN Consulting Full time

    ***FULLY REMOTE 5x8HR DAY SHIFT*****Acute care nursing experience is required.Clinical Documentation Specialist (RN)Shift: 5x8HR DAYS (8:00-16:30) this will be fully remote and not patient facingLength: 13 weeksTime Off: Please include all RTO at applyRequirement: AS of Nursing required, BLS of Nursing or healthcare is preferred. Active WA or Compact RN...


  • Orlando, FL, United States Orlando Health Full time

    CDI Specialist I Registered Nurse - Clinical Documentation - Arnold Palmer HospitalPosition Summary Provides concurrent review of the clinical documentation in the medical record; review the medical record with a clinical lens to identify any missing or understated diagnoses or procedures. This is a hybrid position, hospital will be Arnold Palmer Childrens...


  • Orlando, FL, United States Orlando Health Full time

    CDI Specialist I Registered Nurse - Clinical Documentation - Arnold Palmer HospitalPosition Summary Provides concurrent review of the clinical documentation in the medical record; review the medical record with a clinical lens to identify any missing or understated diagnoses or procedures. This is a hybrid position, hospital will be Arnold Palmer Childrens...


  • St. Petersburg, United States Johns Hopkins Medicine Full time

    You were meant for Hopkins Come see why the Johns Hopkins Hospital is a world-renowned leader in patient care, serving the greater Baltimore community and patients from all across the globe. Our friendly and knowledgeable staff teams provide support throughout our many specialty departments and centers, from primary visits to emergency care. What Awaits You?...


  • , NJ, United States RWJ Barnabas Full time

    The Clinical Document Specialist is responsible for ensuring accurate and compliant physician documentation in the electronic medical record. When Physician Documentation is accurate and compliant it increases reimbursement, improves quality outcomes and allows for disease tracking/trending.Qualifications:Required:* Must be a graduate from an accredited...


  • St. Petersburg, United States Johns Hopkins Medicine Full time

    You were meant for Hopkins! Come see why the Johns Hopkins Hospital is a world-renowned leader in patient care, serving the greater Baltimore community and patients from all across the globe. Our friendly and knowledgeable staff teams provide support throughout our many specialty departments and centers, from primary visits to emergency care. What Awaits...


  • , NJ, United States RWJBarnabas Health Full time

    Clinical Document Specialist, Clinical Documentation ManagementReq #:0000148777Category:NursingStatus:Full-TimeShift:DayFacility:Cooperman Barnabas Medical CenterDepartment:Clinical Documentation MgmtLocation:Cooperman Barnabas Medical Ctr, 94 Old Short Hills Road, Livingston, NJ 07039The Clinical Document Specialist is responsible for ensuring accurate and...


  • Jacksonville, FL, United States Saint Vincent's Medical Center Riverside Full time

    Clinical Documentation Improvement RN Specialist Details * Department: Total Quality Management * Schedule: Full Time, Day Shift, Monday - Friday, 8am - 4:30pm * Hospital: Ascension St. Vincent's Riverside * Location: Jacksonville, FL This is a remote position. Benefits Paid time off (PTO) Various health insurance options & wellness...


  • , TN, United States RN Staff Full time

    Traveler s permanent residence must be 100 miles or > from the hospital s service area.General orientation will begin on Sundays. Sunday will be online CBLs. I can start the traveler any Sunday that you can complete the compliance documents by the deadline. Please include in the confirmation: 16 hours of nonbillable orientation. Hospital can cancel/call off...


  • , TN, United States RN Staff Full time

    Traveler s permanent residence must be 100 miles or > from the hospital s service area.General orientation will begin on Sundays. Sunday will be online CBLs. I can start the traveler any Sunday that you can complete the compliance documents by the deadline. Please include in the confirmation: 16 hours of nonbillable orientation. Hospital can cancel/call off...


  • St. Petersburg, United States MASC Medical Full time

    Company: We have been offering medical research to residents of Central Florida since 2000. With six privately-owned clinical trial facilities our mission is to provide consistent, high-quality clinical research in a professional, ethical and timely manner.   We are looking for a Principal Investigator who can contribute immediately to our rapidly growing...


  • St Petersburg, United States Insight Global Full time

    MUST HAVEPrefer 5 - 7 years of hands-on experience in IBM ITX.At least 3 years of extensive Java development experience.Minimum of 2 years of intensive experience with IBM ACE.Strong understanding of ESB concepts, ESB Design patterns, and Solution Architecture.Proficiency in IBM ACE, IBM MQ Linux, with a background in migration from IBM ACE to Java.Expertise...


  • St. Petersburg, United States Insight Global Full time

    MUST HAVEPrefer 5 - 7 years of hands-on experience in IBM ITX.At least 3 years of extensive Java development experience.Minimum of 2 years of intensive experience with IBM ACE.Strong understanding of ESB concepts, ESB Design patterns, and Solution Architecture.Proficiency in IBM ACE, IBM MQ Linux, with a background in migration from IBM ACE to Java.Expertise...


  • St Petersburg, United States Insight Global Full time

    MUST HAVEPrefer 5 - 7 years of hands-on experience in IBM ITX.At least 3 years of extensive Java development experience.Minimum of 2 years of intensive experience with IBM ACE.Strong understanding of ESB concepts, ESB Design patterns, and Solution Architecture.Proficiency in IBM ACE, IBM MQ Linux, with a background in migration from IBM ACE to Java.Expertise...