Manager, Clinical Documentation

Description

The Manager of Clinical Documentation Improvement (CDI) leads the enterprise CDI program to ensure accurate, complete, and compliant clinical documentation that reflects the true severity of illness, risk of mortality, and quality of care delivered. This leader oversees CDI workflows across inpatient and outpatient settings, partners closely with Coding, HIM, Revenue Cycle, Quality, and Medical Staff, and drives performance in metrics tied to case mix index (CMI), query response rates, DRG accuracy, severity capture, and publicly reported quality measures. The role is accountable for program strategy, team development, operational excellence, and alignment with organizational goals.

Responsibilities

This is not an exhaustive statement of duties, responsibilities, or requirements. Employees will be required to perform any job, with related instruction given by their supervisor, subject to reasonable accommodation.

Program Leadership and Strategy

o Develop and execute the CDI strategy across service lines; set goals, KPIs, and dashboards tied to financial integrity and quality outcomes.

o Lead daily operations for CDI (worklists, prioritization, query standards, escalation pathways, coverage models, and service levels).

o Standardize policies, procedures, and documentation guidelines; ensure alignment with coding guidelines (ICD-10-CM/PCS), CMS, and payer requirements.

Clinical and Coding Collaboration

o Partner with Coding/HIM to optimize MS-DRG and APR-DRG accuracy, principal diagnosis selection, CC/MCC capture, and denials mitigation.

o Collaborate with Quality and Risk to enhance documentation supporting PSI/HAC exclusions, risk adjustment, and public reporting (e.g., CMS Stars, Leapfrog, Vizient).

o Build strong physician relationships, lead physician education, service line rounds, and specialty documentation initiatives.

People Leadership

o Manage and develop CDI staff (CDI specialists, leads, educators, auditors); oversee hiring, onboarding, training, competency assessments, and performance evaluations.

o Foster a culture of accountability, continuous improvement, and interprofessional collaboration.

Technology and Analytics

o Optimize Epic (e.g., Notes, Problem List, SmartTools, CDI workqueues, reporting).

o Use data to drive decision-making—monitor CMI, query response/agree rates, SOI/ROM, HACs and PSIs, O/E Mortality, length of stay (LOS) alignment, PEPPER/PSI/HAC trends, and denial patterns.

o Partner with IT/Analytics to develop actionable dashboards and root cause analyses.

Compliance and Quality

o Ensure CDI practices comply with AHIMA/ACDIS standards, CMS regulations, and organizational policies.

o Maintain documentation integrity and support clinical validation and audit readiness.

o Lead internal audits and implement corrective actions; track outcomes and sustain improvements.

Financial & Operational Performance

o Measure and report program impact (e.g., net revenue lift, DRG shifts, severity capture, denial avoidance).

o Steward resources—budget planning, productivity standards, and vendor management.

Qualifications

YEARS OF RELATED WORK EXPERIENCE

Minimum: 5 years of progressive CDI experience in an acute care setting and 3 years of leadership experience in a health system.

Preferred: At least 5 years in CDI leadership or supervisory role in a health system. CDI Ambulatory experience.

All job qualifications listed indicate the minimum level necessary to perform this job proficiently.

LEVEL OF EDUCATION

Minimum: Bachelor’s Degree or higher in Nursing, Health Information Management or related field.

Preferred: Master’s degree in a related field.

CERTIFICATIONS, LICENSES, REGISTRATIONS

Minimum: Current RN license or RHIT (Registered Health Information Technician) or RHIA (Registered Health Information Administrator) In addition to RN, RHIT, or RHIA must also posses

CCDS – Certified Clinical Documentation Specialist (ACDIS) or CDIP – Certified Documentation Integrity Practitioner (AHIMA)

Preferred: Current RN License and CCDS or CDIP Certification

TECHNICAL REQUIREMENTS

Minimum: Inpatient experience in Epic. MS Office skills, including intermediate excel experience. Broad knowledge of Medicare guidelines.

Preferred: Intermediate MS Office skills, experience with Epic CDI software and clinical informatics.

YEARS OF RELATED WORK EXPERIENCE

Minimum: 5 years of progressive CDI experience in an acute care setting and 3 years of leadership experience in a health system.

Preferred: At least 5 years in CDI leadership or supervisory role in a health system. CDI Ambulatory experience.

KNOWLEDGE, SKILLS, and ABILITIES

All knowledge, skills, and abilities listed indicate the minimum level deemed necessary to perform this job proficiently.

PROBLEM SOLVING AND DECISION MAKING

Strong critical thinking and analytical skills. Ability to identify the trends and offer solutions.

INTERPERSONAL SKILLS

Assertive personality traits to facilitate ongoing physician communication. Ability to work independently in a time-oriented environment.

COMMUNICATION SKILLS

Excellent written and verbal communication skills; ability to write concisely and effectively when communicating with providers.

OTHER

Ability to develop material and give presentations to groups and committees as required