Job Description

Job Title: Lead, Clinical Documentation Improvement Coding
Job ID: 39014325
Status: Full-Time
Regular/Temporary: Regular
Shift: Day Job
Facility: Corporate Revenue Cycle
Department: Rev Cyc Coding
Location: 104 East Second St, Erie PA 16507


The UPMC team is searching for a Lead Clinical Documentation Improvement (CDI) to support their team at UPMC Hamot! This full time position will supervise the staff performing CDI optimization for inpatients concurrently, as well as post coding DRG optimization, including the coordination of training/education related initiatives for the CDI program.  This role will provide direction and coordination of the work flow among all necessary hospital groups/departments. The Lead will ensure accuracy and timely input of clinical documentation to support severity of illness and risk of mortality scores as well as optimal reimbursement by payers.  Additionally, the lead will interact with physicians regarding clarifications necessary for appropriate coding and clinical documentation standards.

This role will have a consistent shift of Monday through Friday during normal business hours.

  • Adhere to human resource policies and procedures. Assist with the performance reviews for all direct reports.
  • Assist with CDI software program testing and marker evaluations, including providing feedback to vendor and medical director of coding. Investigate staff issues and provide feedback as appropriate on resolution.
  • Assist with the development and implement policies and procedures for processes performed for the CDI program. Provide support, training, develop and guidance to staff in their daily activities.
  • Assist with the one-on-one education with staff identified as having quality or productivity related deficits based on audits conducted within the department. Conduct audits on staff to ensure quality indicators are met. Review findings with appropriate personnel.
  • Coordinate all work distribution for CDI staff. Provide education and audit related feedback to enhance the coding knowledge base of all inpatient coding.
  • Perform CDI related work duties (i.e., work CDI patient list and markers regularly to ensure work production requirements are met).
  • Perform duties and responsibilities in a fashion that coincides with the service management philosophy of UPMC including the demonstration of the basics of service excellence towards patients, visitors, staff, peers, physicians and other departments within the medical center.
  • Provide education related sessions on CDI requirements during staff meetings and other sessions as applicable, including physicians.
  • Review work flow to maximize automated systems. Assist with training of new staff.
  • When necessary, complete CDI functions to ensure minimal backlogs exists.


  • Three years of previous clinical documentation improvement specialist AND three years of experience with the Prospective Payment System and DRG selection/assignment and optimization.
  • Bachelors degree or equivalent years of experience in related field.  
  • Knowledge of computer technology, quality assurance activities, DRG, Quality Insights/Utilization review background is highly preferred. 
  • Certified Clinical Documentation Specialist (CCDS) certification highly preferred.
  • Strong experience with electronic documentation and electronic medical record content. 
  • Prior supervisory experience preferred.   
  • Ability to communicate with staff, physicians, healthcare providers, and other health care system personnel in a professional and diplomatic manner required.

Licensure, Certifications, and Clearances:
  • Certified Coding Specialist or Registered Health Information Administrator or Registered Health Information Technician or Registered Nurse

UPMC is an equal opportunity employer. Minority/Females/Veterans/Individuals with Disabilities

Salary Range: $24.08 to $41.23 / hour

Union Position: No

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