Director of Clinical Optimization

About the role

The Director of Clinical Optimization is responsible for leading initiatives that improve the accuracy and completeness of clinical documentation, severity of illness (SOI), risk of mortality (ROM), case mix index (CMI), hierarchical condition category (HCC) capture, and risk adjustment across the continuum of care. This leader serves as the operational bridge between providers, Clinical Documentation Integrity (CDI), Coding, Case Management, Population Health, Finance, Quality, and Information Technology to ensure documentation accurately reflects the complexity of patients while supporting quality outcomes, value-based reimbursement, and regulatory compliance.

The Director develops a comprehensive clinical optimization strategy focused on inpatient, outpatient, ambulatory, and population health documentation. The role ensures that every patient encounter accurately reflects the true complexity of care, resulting in: improved quality outcomes, more accurate risk-adjusted performance, enhanced reimbursement integrity, stronger value-based performance, reduced documentation-related denials, better physician engagement, and improved patient care through accurate clinical representation.

Responsibilities

• Developing and overseeing the Clinical Optimization Program
• Improving documentation supporting Severity of Illness (SOI), Risk of Mortality (ROM), Case Mix Index (CMI), Expected Mortality, and Expected Length of Stay
• Partnering with CDI and Coding to identify documentation opportunities
• Standardizing physician documentation best practices across all hospitals
• Leading Risk Adjustment & HCC initiatives to improve HCC capture, RAF accuracy, chronic disease documentation, annual wellness documentation, risk adjustment education, Medicare advantage documentation, and ambulatory coding optimization
• Collaborating with Primary Care, Specialists, Population Health, Value-Based Care, and Care Management
• Partnering with Quality teams to improve Vizient Mortality, Readmissions, Patient Safety Indicators, Hospital Acquired Conditions, CMS Star Measures, Quality Blue, Peak Health, Value Based Purchasing, DPP measures, MSSP/ACO quality metrics
• Ensuring documentation appropriately reflects patient acuity for quality benchmarking
• Working on Pre-bill HAC, PSI, and other reviews
• Developing physician engagement strategies including documentation education, specialty-specific scorecards, provider dashboards, peer comparison reports, one-on-one physician coaching, medical staff presentations, and new provider onboarding
• Partnering with physician advisors and medical staff leadership
• Monitoring regional performance including Case Mix Index, SOI/ROM, Mortality Index, observed vs Expected Mortality, Readmission Index, HCC capture rates, RAF scores, Query response rates, Documentation opportunities, Clinical validation trends, and Denial trends
• Developing executive dashboards for leadership
• Partnering with Information Technology and Analytics to optimize Ambulatory Documentation Initiative, Annual HCC Refresh Campaign, Clinical Documentation Scorecards, and Executive Documentation Dashboard
• Accountability for improvements in Case Mix Index (CMI), Severity of Illness (SOI), Risk of Mortality (ROM), Expected Mortality, Observed/Expected Mortality, Vizient rankings, HCC Capture Rate, RAF Accuracy, Provider Query Response Rate, Query Agreement Rate, Readmission Index, Length of Stay Index, Documentation-related denials, Coding accuracy, and Clinical validation success rate

Minimum Qualifications

Education: Bachelor of Science degree in Nursing or related healthcare field required. Current Registered Nurse license issued by the state in which services will be provided or current multi-state Registered Nurse license through the enhanced Nurse Licensure Compact (eNLC). Other clinical licensure may be considered. Obtain certification in Basic Life Support within 30 days of hire date.

Experience: Seven (7) years of progressive healthcare leadership. Experience in CDI, Coding, Quality Improvement, Population Health, Value-Based Care, Physician Engagement, Clinical Documentation, and Hospital Operations.

Preferred Qualifications

• Master's degree (MSN, MHA, MBA, MPH, or equivalent)
• Association of Clinical Documentation Integrity Specialists Certified Clinical Documentation Specialist (CCDS)
• American Health Information Management Association Certified Coding Specialist (CCS)
• American Academy of Professional Coders Certified Professional Coder (CPC)
• National Association of Healthcare Quality Certified Professional in Healthcare Quality (CPHQ)
• Lean Six Sigma Green Belt or Black Belt
• Certified Risk Adjustment Coder (CRC)

Skills and Abilities

• Ability to promote a positive work environment with a team approach to patient and families
• Ability to actively listen and promote shared governance within the program area
• Ability to participate in continuing education and training
• Conflict resolution skills
• Strong interpersonal and communication skills