Manager, Clinical Documentation Specialist

Job Summary

The Manager, Clinical Documentation Improvement (CDI) oversees centralized CDI operations to support the accuracy, completeness, and integrity of clinical documentation related to coding, reimbursement, quality outcomes, and regulatory compliance. This role manages CDI operational performance, supports staff development, and collaborates with providers, coding teams, and clinical leadership to promote compliant documentation practices and achievement of organizational CDI objectives.

This position requires 50% travel to GA, IN, MO, OK, NM. 

Essential Functions

• Manages daily CDI operations and oversees documentation improvement activities to support accurate reflection of patient severity, acuity, and complexity of care.
• Monitors CDI operational performance, including key performance indicators, quality metrics, productivity, and documentation trends, and implements improvement strategies aligned with organizational goals.
• Provides education and guidance to providers and CDI staff regarding documentation practices, compliant query processes, coding guidelines, and regulatory requirements.
• Supervises CDI staff performance, including coaching, competency assessment, performance evaluation, onboarding, and professional development activities.
• Collaborates with coding, HIM, quality, care management, facility leadership, and clinical teams to support documentation integrity, reporting accuracy, reimbursement, and quality outcomes.
• Supports development and implementation of CDI workflows, tools, query templates, and operational processes in alignment with organizational standards.
• Analyzes clinical documentation and operational data to identify trends, risks, and opportunities for process improvement and performance enhancement.
• Participates in audits, compliance reviews, reporting activities, and regulatory readiness initiatives related to CDI operations.
• Maintains current knowledge of evolving coding guidelines, documentation standards, reimbursement methodologies, and regulatory requirements and communicates updates to stakeholders.
• Travels up to 50% to assigned facilities to support CDI operations, education, performance improvement initiatives, and operational alignment.
• Performs other duties as assigned.
• Maintains regular and reliable attendance.
• Complies with all policies and standards.

Qualifications

• Associate Degree in Nursing or a comparable clinical field required
• Bachelor's Degree in Nursing, Health Information Management, or a related field preferred
• 5-7 years of acute care hospital clinical experience required
• 2-4 years of experience in clinical documentation improvement required
• Experience providing physician or provider education and mentoring CDI staff required
• Experience in critical care, case management, utilization review, quality, or inpatient coding preferred
• CDI leadership, lead, or supervisory experience preferred

Knowledge, Skills and Abilities

• Advanced knowledge of clinical documentation review practices, disease processes, clinical care standards, and medical terminology.
• Knowledge of ICD-10-CM/PCS coding principles, MS-DRG/APR-DRG methodologies, and inpatient prospective payment systems.
• Strong verbal and written communication skills, including the ability to provide education and feedback to providers and interdisciplinary teams.
• Strong critical thinking and problem-solving skills with the ability to interpret and apply coding and documentation guidelines in complex clinical scenarios.
• Proficiency with CDI software, encoder tools, electronic medical records, and standard office software applications.
• Ability to lead, mentor, and support professional development of CDI staff.
• Ability to manage multiple priorities, meet deadlines, and work independently in a fast-paced environment.
• Demonstrated professionalism, collaboration, and leadership in interdisciplinary healthcare environments.

Licenses and Certifications

• DL NUMBER - Driver License, Valid and in State required
• RN - Registered Nurse - State Licensure and/or Compact State Licensure or comparable clinical license (e.g., International MD) required
• CDIP - Clinical Documentation Improvement Professional obtained within 6 months of hire date required or
• Certified Clinical Documentation Specialist (CCDS) obtained within 6 months of hire date required
• RHIT - Registered Health Information Technician preferred or
• RHIA - Registered Health Information Administrator preferred
• CCS-Certified Coding Specialist or ICD-10 certification or trainer designation preferred or
• Certified Coder-AHIMA or AAPC preferred