CDI RN Lead

Summary/Objective

The CDI RN Lead serves as a clinical subject matter expert and frontline leader for the Clinical Documentation Improvement program. This role is responsible for coordinating program elements, mentoring staff, and driving physician engagement to ensure documentation accurately reflects patient complexity, severity of illness, and risk of mortality. The Lead ensures to program aligns with compliance standards and organizational goals while fostering a culture of continuous improvement.

Essential Job Functions

• Acts as a primary point of contact for the CDI team; coordinates and maintains all program elements to meet organizational goals and balanced scorecard metrics.

• Ensures timely, accurate and complete clinical documentation to support high-quality data for physician and hospital outcome reporting.

• Serves as a liaison between CDI and Coding professionals; proactively resolves discrepancies and facilitates a unified approach to clinical code assignment.

• Analyzes program data and key performance indicators; creates comprehensive reports to identify trends, gaps, and opportunities for documentation improvement.

• Develops and delivers education for CDI staff and physicians; provides ongoing mentorship to team members to enhance clinical knowledge and query proficiency.

• Maintains effective communication with stakeholders (e.g. Quality, Revenue Cycle, Physician Leaders) to build credibility and trust.

• Ensures all departmental activities comply with company policies, HIPAA regulations, and official coding guidelines.

Key Success Indicators/Attributes: 

• Ability to prioritize and multi-task in a multifaceted environment.
• Demonstrate strong organizational skills and be detail oriented.
• Demonstrate ability to self-motivate, set goals, and meet deadlines.
• Demonstrate mentoring and interpersonal skills. 
• Demonstrate excellent presentation, verbal, and written communication skills.

• Ability to develop and maintain relationships with key business partners by building personal credibility and trust.

• Maintains courteous and professional working relationships with employees at all levels of the organization.

• Demonstrate successful leadership skills with the use of critical thinking, problem solving, and deductive reasoning required.

• Specialized training in advanced computer skills with proficiency in Microsoft Word, Excel, Power Point, and Outlook e-mail required

• Additional training in Access database management, Medicare Part A and B programs, DRG assignment, and knowledge of MCC/CC preferred

   

Work Environment

This job operates in a remote home office environment. This role routinely uses standard office equipment such as computers and phones.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.

While performing the duties of this job, the employee is occasionally required to stand; walk; sit; use hands to finger, handle, or feel objects, tools, or controls; reach with hands and arms; climb stairs; balance; stoop, kneel, crouch or crawl; and talk or hear. The employee must occasionally lift or move up to 25 pounds. Specific vision abilities required by the job include close vision, distance vision, peripheral vision, depth perception and the ability to adjust focus.

Position Type/Expected Hours of Work

This is a full-time position. Days and hours of work are generally Monday through Friday, 8:00 a.m. to 5 p.m. This position occasionally requires long hours and weekend work.

Travel

Minimal travel required; up to 5%

Required Education and Experience

• Bachelor’s degree in nursing (BSN) or a healthcare related field.
• Active, unrestricted Registered Nurse (RN) license. 
• 3-5 years of experience in a Clinical Documentation Improvement Program.
• Minimum of 3 years in a management, supervisory, or Lead role within a clinical quality or CDI environment.
• Deep understanding of Medicare Part A and B, DRG assignment, and MCC/CC impact.
• CCDS (ACDIS) or CDIP (AHIMA) preferred.

Additional Eligibility Qualifications

None required

Security Access Requirements

In addition to the specific security access required by the employee’s client engagement, the employee will have access to the Omega systems set forth in "Standard Field Employee” profile.

• Microsoft Office: E1 Level Access

• ADP: Standard Employee Level Access

• Oracle: Standard Level Access

Equal Employment Opportunity:

Omega Healthcare is an Equal Employment Opportunity employer. All qualified applicants will receive consideration for employment without regard to their race, color, religion, national origin, gender, age, sexual orientation, gender identity or expression, marital status, mental or physical disability, protected veteran status, and genetic information, or any other basis protected by applicable law. Omega Healthcare also prohibits harassment of applicants or employees based on any of these protected categories.

Omega Healthcare makes reasonable accommodations when needed for applicants and candidates with disabilities or religious observances. If reasonable accommodation is needed to participate in the job application, interview, or any other part of the hiring process, please contact Human Resources at employeerelationsus@omegahms.com

Other Duties

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job.  Duties, responsibilities, and activities may change at any time with or without notice. Employee may perform other duties as assigned.