Clinical Documentation Improvement Manager

Clinical Documentation Improvement Manager (CDI)

Position Summary

We are seeking an experienced Clinical Documentation Improvement (CDI) Manager to lead documentation integrity initiatives in a collaborative acute care environment.

This role partners closely with physicians, nursing, coding, quality, and revenue cycle teams to ensure clinical documentation accurately reflects patient acuity, severity of illness, and quality outcomes. The CDI Manager will oversee documentation improvement strategies, support the physician query process, and analyze documentation trends to improve compliance, quality metrics, and reimbursement accuracy.

This position is open to Registered Nurses, Physicians / International Medical Graduates, and Health Information Management professionals with CDI leadership experience.

Key Responsibilities

Lead and support hospital-wide clinical documentation improvement initiatives
• Oversee and guide the concurrent physician query process
• Identify documentation opportunities through chart review and data analysis
• Ensure documentation supports accurate ICD-10 coding and MS-DRG / APR-DRG assignment
• Collaborate with physicians, advanced practice providers, HIM, coding, quality, and revenue cycle teams
• Monitor documentation related to Severity of Illness (SOI), Risk of Mortality (ROM), and medical necessity
• Analyze CDI metrics and implement process improvements and best practices
• Educate providers and staff on documentation standards and regulatory guidelines
• Maintain compliance with CMS, UHDDS, and payer requirements

Minimum Qualifications

Minimum 2 years of CDI leadership or supervisory experience

Candidates MUST hold one of the following CDI certifications:

Certified Clinical Documentation Specialist (CCDS)

Certified Clinical Documentation Specialist – Outpatient (CCDS-O)

Certified Documentation Improvement Practitioner (CDIP)

Registered Nurse Pathway

Education & Experience

Graduate of an accredited school of nursing

5+ years clinical nursing experience

3+ years CDI experience

Licensure

Active Nevada Registered Nurse license

Physician / International Medical Graduate Pathway

Education & Experience

Medical Degree (MD) – International Medical Graduates encouraged to apply

5+ years acute care clinical experience

1+ year CDI experience

HIM / Coding Pathway

Education & Experience

Bachelor’s degree in Health Information Management, Health Information Technology, or related field
• 4+ years coding and medical record abstraction experience in an acute care hospital

Required Coding Certification (one of the following)

CCS

RHIT

RHIA

CPC

CPC-P

Why Join Our Team?

Opportunity to lead and influence clinical documentation strategy

Work collaboratively with physician leadership and interdisciplinary teams

Direct impact on quality metrics, patient outcomes, and hospital performance

Supportive environment focused on professional growth and CDI best practices

Competitive compensation based on experience and credentials