Lead Clinical Documentation Integrity Specialist

Facility: Administrative Regional Training Cntr Shift: Shift 1 Status: Full Time FTE: 1.000000 Bargaining Unit: ACE Associates Exempt from Overtime: Exempt: Yes Work Schedule: Days Hours: 8-4 Summary: Under the direction of the Manager Clinical Documentation Integrity, the Lead Clinical Documentation Integrity Specialist is responsible for leading various training and operational matters including appropriate scheduling and coverage of cases, reconciling queries and DRG discrepancies, educating physicians, monitoring the program, and refining the process as needed, as well as training and mentoring new and current staff with regard to compliant documentation. The lead also serves as a secondary review/escalation point for potential or unanswered provider queries. The Lead Clinical Documentation Integrity Specialist is responsible for identifying areas of focus and necessary process refinements through report analysis. Leads CDI team in enacting process changes and measuring efficacy and impact of results. Serves as a resource t physicians and administration regarding issues related to the appropriateness of inpatient DRG assignment. Coordinates follow-up audits to ensure full compliance with regulatory requirements. Responsibilities: EDUCATION + Bachelor of Science Nursing (BSN) degree + Registered Nurse with a current New York State license CERTIFICATION + Certified Clinical Documentation Specialist (CCDS) is required within a year of hire + Must maintain New York State RN license EXPERIENCE + Minimum five (5) years of experience working within Clinical Documentation Integrity required + Five (5) years of clinical experience in an acute care setting as an Inpatient nurse or Case/Utilization Manager preferred KNOWELDGE, SKILL AND ABILITY + Demonstrated understanding of complications, co-morbidities, severity of illness, risk of mortality + Knowledge of ICD-10, current knowledge of coding clinics including recent changes/updates, and understanding of the various DRG methodologies (AP-DRG and MS-DRG) + Extensive clinical knowledge and understanding of pathology/physiology; best demonstrated by clinical experience in hospital setting. + Self-Confident personality traits to facilitate ongoing physician communication + Excellent interpersonal communication (oral and in writing) and networking skills + Excellent critical thinking, discernment, and clinical assessment skills + Ability to relate well and establish partnerships with the providers to maximize the quality of documentation for Catholic Health patients + Ability to work independently in a time-oriented environment. + Knowledge of Microsoft office, word, excel and power point; Webex programs WORKING CONDITIONS + Routine travel between acute care facilities and ambulatory offices ENVIRONMENT + Normal heat, light space, and safe working environment; typical of most office jobs

Created: 2026-02-19