CDI Team Lead (Clinical Documentation Integrity Validation Specialist)

CDI Team Lead (Clinical Documentation Integrity Validation Specialist)

Company: Radost Solutions Location: Remote (US-based candidates only) Employment Type: Full-time Department: Clinical Documentation

Company Overview

Radost Solutions is a growing consulting firm based in Portland, Oregon, specializing in innovative solutions for complex business challenges within the healthcare industry. We are dedicated to delivering exceptional service and expertise to our clients, connecting qualified professionals with meaningful opportunities in healthcare technology and clinical settings. Learn more about us at www.radost.us.

About the Client

Our client is a leading academic medical center and health system committed to delivering exceptional patient care, advancing medical research, and training the next generation of healthcare professionals. The organization is seeking an experienced Clinical Documentation Integrity (CDI) Team Lead to strengthen its documentation program, drive audit and education initiatives, and support quality outcomes across the inpatient setting.

Position Summary

The CDI Team Lead (CDI Validation Specialist) assists the CDI Manager with oversight, evaluation, and analysis of CDI functions including efficiency, accuracy, continuing education needs, and overall quality. This role identifies individual education needs of Clinical Documentation Specialists and collaborates with the CDI Manager, IP Coding Manager, and IP Coding Validation Manager to develop appropriate training materials.

The primary goal of this role is to ensure documentation in the chart accurately identifies all clinical findings, diagnoses, and procedures, and that these are appropriately and clinically supported. The CDI Team Lead works alongside the CDI Manager to leverage team performance, providing feedback and influence to continually improve documentation results and positively impact key performance indicators.

The CDI Team Lead functions as an interdisciplinary auditor and educator, focusing primarily on ensuring physician documentation is complete, accurate, and representative of the care provided. The position has access to physicians and clinical staff to support the ongoing documentation improvement effort and reports directly to the CDI Manager.

Important: This role is not open to C2C or C2H arrangements and is only available to candidates legally authorized to work in the United States.

Key Responsibilities

Audit, Quality, and Validation
• Monitor CDI staff accuracy, data quality, and data integrity
• Monitor the CDS review process for content, timeliness, and accurate diagnosis and procedure assignment in determining a working DRG
• Monitor concurrent queries for compliance, accuracy, clarity, and timeliness
• Audit Clinical Documentation Specialists retrospectively to assess completeness of chart review and query compliance, including missed query opportunities, accurate coding, and adherence to AHIMA/ACDIS compliant query guidelines and standards
• Review charts concurrently with no MCC/CCs, low SOI/ROM, and LOS not supported by the working DRG
• Assist the CDI Manager with final DRG validation when there is a discrepancy between the CDS and coder
• Review and analyze denial claims and denial data to support denial prevention strategies through the clinical validation query process
• Audit mortality and readmission cohorts to identify opportunities for improvement and contribute to departmental and organizational quality performance goals

Education and Team Development
• Identify missed query opportunities and educate CDI staff accordingly
• Collaborate with the CDI Manager to identify, coordinate, and implement ongoing CDI specialist education and feedback based on audit findings
• Assist in the orientation and training of new Clinical Documentation Specialists
• Provide CDI specialists, coders, and coding validation specialists with clinical feedback to support accurate capture of diagnoses and identification of post-discharge physician query opportunities
• Serve as a resource for CDI informational needs and update the team on coding changes, medical science updates, and CDI practice standards
• Provide timely, appropriate feedback to the CDI Manager on any performance improvement plans for CDI staff

Process, Leadership, and Collaboration
• Collaborate with the CDI Manager to create and update documentation tools, processes, procedures, and workflows on an ongoing and as-needed basis
• Collaborate with the CDI Manager, IP Coding Manager, and IP Coding Validation Manager to strategize appropriate training methodology for individual issues
• Collaborate with other CDCI department managers to identify areas for improvement and implement process improvement solutions
• Track trends in documentation concerns and implement solutions for improvement
• Use leadership and critical thinking skills to identify opportunities for team processes and engagement
• Assist the CDI Manager, when requested, in the development of APR-DRG and query response physician reports
• Assume operational oversight of the CDI department in the absence of the CDI Manager

Compliance and Professional Development
• Ensure documentation is compliant with federal and state regulations, coding guidelines, and hospital policies
• Remain current in clinical and coding/documentation-related materials, including CDS best practices as defined by ACDIS, ICD-10-CM/PCS, AHA Coding Clinic guidelines, and MS-DRG/APR-DRG classification systems
• Monitor regulatory and reimbursement changes
• Evaluate the success of concurrent documentation improvement on an ongoing basis
• Maintain complete confidentiality of patient information, hospital data, and individual physician practice pattern data
• Advance professional growth and development through participation in educational programs, workshops, and by maintaining knowledge of industry standards and practices
• Adhere to all client organizational behavioral standards
• Other duties as assigned

Required Qualifications
• Bachelor's degree (or equivalent) in Nursing, Health Information Management, or a related field
• Minimum of five (5) years of experience in clinical documentation, or an equivalent combination of education and experience
• Strong knowledge of ICD-10-CM/PCS, MS-DRG and APR-DRG classification systems, and AHA Coding Clinic guidelines
• Familiarity with AHIMA/ACDIS compliant query guidelines and standards
• Demonstrated experience auditing CDI work, providing education, and delivering constructive feedback
• Strong analytical, critical thinking, and communication skills

Preferred Qualifications
• CCDS, CDIP, CCS, or RHIA/RHIT credentials
• RN licensure
• Prior experience in a CDI team lead, senior CDI, or CDI auditor/educator role
• Experience reviewing denials and supporting denial prevention strategies
• Experience with mortality and readmission reviews

Work Environment
• Fully remote position
• Collaborative healthcare environment with cross-functional clinical, coding, and leadership teams
• Fast-paced, high-visibility role requiring strong organizational and stakeholder management skills

Benefits
• Competitive compensation
• 401(k) retirement plan
• Health insurance stipend
• Paid Time Off
• Paid Holidays
• Professional development opportunities

Application Requirements

Qualified candidates must:
• Be legally authorized to work in the United States
• Have reliable high-speed internet and a professional home office setup
• Be available for full-time engagement

Radost Solutions is an equal opportunity employer, welcoming diversity and inclusivity in our workforce. We do not engage in discrimination based on any personal attributes.

Job Type: Full-time Work Location: Remote

Pay: $49.74 per hour

Benefits:
• 401(k)
• Health insurance
• Paid time off

Application Question(s):
• Do you have a Bachelor's degree (or equivalent) in Nursing, Health Information Management, or a related field
• Do you have a miinimum of five (5) years of experience in clinical documentation, or an equivalent combination of education and experience
• Do you have a strong knowledge of ICD-10-CM/PCS, MS-DRG and APR-DRG classification systems, and AHA Coding Clinic guidelines
• Are you familiar with AHIMA/ACDIS compliant query guidelines and standards

Work Location: Remote