Clinical Documentation Improvement Manager

Join our team as a leader in Clinical Documentation Improvement (CDI) with a strong background as a Second Level Reviewer and certification in CDI. This role requires a broad clinical knowledge base and a deep understanding of DRG documentation requirements.

About the role

Manage daily CDI operations and activities, ensuring high performance and professional development of the CDI team. Conduct concurrent secondary and retrospective medical record reviews for defined patient populations to identify opportunities for improving documentation accuracy. Collaborate with the Quality team, Case Managers, and Coding department to ensure documentation is clinically appropriate, accurately reflects patient severity of illness, and aligns with current CMS standards.

Reports directly to the Director of CDI.

Responsibilities

• Oversee daily Clinical Documentation Integrity (CDI) operations and staff activities.
• Lead, coach, mentor, and evaluate CDI specialists to ensure high performance and professional development.
• Monitor documentation quality, query practices, productivity, and departmental performance metrics.
• Collaborate with physicians, advanced practice providers, coding, case management, quality, and revenue cycle teams to improve clinical documentation accuracy and completeness.
• Develop and deliver provider education related to documentation requirements, coding regulations, severity of illness (SOI), risk of mortality (ROM), and quality measures.
• Ensure compliance with CMS regulations, coding guidelines, accreditation standards, and industry best practices.
• Analyze CDI data and trends, including Case Mix Index (CMI), query response rates, CC/MCC capture, and denial metrics, and implement improvement strategies.
• Support accurate reimbursement through complete and compliant clinical documentation.
• Assist with audits, denials management, and regulatory reviews related to documentation and coding.
• Partner with Quality and Patient Safety teams to improve outcomes, risk adjustment, mortality measures, patient safety indicators (PSIs), and publicly reported quality metrics.
• Establish departmental goals, monitor key performance indicators, and provide regular reports to executive leadership.
• Complete concurrent secondary reviews of targeted patient populations to identify missed opportunities and accurate selection of principal diagnosis.
• Act as liaison between the Coding Department and the Clinical Documentation Specialist to reconcile discrepancies in DRG assignment.
• Analyze and interpret clinical data to identify gaps, inconsistencies, and/or opportunities for improvement in clinical documentation, and appropriately query the provider using a concurrent or retrospective query process; follow up to ensure queries are answered.
• Assign the appropriate DRG, MCCs, and CCs to each record reviewed.
• Organize and perform work responsibilities effectively and efficiently.
• Maintain strict patient confidentiality, adhering to HIPAA guidelines.
• Demonstrate standards of performance (ownership, teamwork, communication, compassion) that support patient satisfaction and principles of service excellence.
• Perform other duties as assigned.

Requirements

• Registered Nurse/BSN, RHIA, RHIT, or related clinical allied health degree required; Physician Assistant (PA) preferred.
• Certification: CCS, CCDS, or CDIP required.
• Minimum of 5 years’ experience as a Clinical Documentation Specialist required; 7 or more years preferred.
• Minimum of 2 years supervisory experience required; 3-5 years preferred.

Skills

• Advanced clinical expertise and extensive knowledge of complex disease processes with broad clinical experience in an inpatient setting.
• Ability to exchange accurate information with patients, families, peers, and medical personnel.
• Must be able to respond quickly and effectively to emergency and non-emergent situations.
• May be required to assist in controlling disorderly conduct or combative patients.

Physical Demands / Work Environment

• Work requires a variety of physical activities, including moving about within and outside of all hospital properties for long periods of time.
• Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.