Manager, Clinical Documentation

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.

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.

1.

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

* Lead daily operations for CDI (worklists, prioritization, query standards, escalation pathways, coverage models, and service levels). * Standardize policies, procedures, and documentation guidelines; ensure alignment with coding guidelines (ICD-10-CM/PCS), CMS, and payer requirements.

Percentage of time: 20% 2.

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

* Collaborate with Quality and Risk to enhance documentation supporting PSI/HAC exclusions, risk adjustment, and public reporting (e.g., CMS Stars, Leapfrog, Vizient). * Build strong physician relationships, lead physician education, service line rounds, and specialty documentation initiatives 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