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Lead Clinical Documentation Specialist

Company: VirtualVocations
Location: Vista
Posted on: May 16, 2025

Job Description:

A company is looking for a Lead CDI Specialist to oversee the Clinical Documentation Integrity program and improve medical record documentation quality.
Key Responsibilities

Assist in planning and directing day-to-day operations of the CDI program
Facilitate improvement in the quality, completeness, and accuracy of medical record documentation through audits and education
Perform pre-bill compliance audits and ensure accurate code assignment and compliance with regulations

Required Qualifications

Minimum of three (3) years of experience as a Clinical Documentation Integrity Specialist
Bachelor's degree (preferably BSN) or an Associate of Science in Nursing with two (2) years of relevant clinical experience
Certification as a Certified Documentation Improvement Practitioner (CDIP) or Certified Clinical Documentation Specialist (CCDS) within one (1) year
Proficiency in Microsoft Excel and Outlook
Regular and predictable attendance is required

Keywords: VirtualVocations, Diamond Bar , Lead Clinical Documentation Specialist, Healthcare , Vista, California

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