Clinical Documentation Improvement (CDI) Lead

Under general supervision of the CDI Manager following established policies, procedures and professional guidelines serves as a Lead CDI Specialist and second level reviewer for the department. The CDI Lead is an expert clinician who works in partnership with multidisciplinary teams, including but not limited to Coding, Quality, Infection Control and medical staff to improve the quality and accuracy of the medical record documentation. The CDI Lead monitors the accurate reporting of SOI/ ROM scores and MCC /CC capture rates for DRGs assigned. The CDI Lead maintains clinical and professional competencies for subject matter expertise in clinical documentation improvement concepts. They are responsible for concurrently reviewing inpatient medical records to identify vague, inconsistent or incomplete documentation within the medical record and assign the most appropriate medical severity diagnostic related group (MS-DRG). Further clarification of the principal and secondary diagnoses is carried out by collaborating with the physician(s) and/or care provider designees as appropriate. Participates in the educational and onboarding process of new team members.