Clinical Documentation Improvement Manager

Lake Charles Memorial Hospital • Lake Charles, LA

11h • Onsite

About The Position

The Clinical Documentation Improvement (CDI) Manager has experience as a Second Level Reviewer, is certified in CDI, and possesses a broad clinical knowledge base with an understanding of DRG documentation requirements. This role involves managing daily CDI operations and activities, leading, coaching, and evaluating CDI specialists to ensure high performance and professional development. The manager will conduct concurrent secondary and retrospective medical record reviews for defined patient populations to identify opportunities for improving documentation accuracy. This role collaborates with the Quality team, Case Managers, and the Coding department to ensure documentation is clinically appropriate, accurately reflects the severity of illness for the patient, and aligns with current CMS standards.

Requirements

• Registered Nurse/BSAN, RHIA, RHIT, or related clinical allied health degree required, or Physician Assistant (PA) preferred
• CCS, CCDS, or CDIP required
• Minimum of 5 years experience as a Clinical Documentation Specialist required
• Minimum of 2 years supervisory experience required
• Advanced clinical expertise and extensive knowledge of complex disease processes with a broad clinical experience in an inpatient setting required.

Nice To Haves

• Physician Assistant (PA) preferred
• 7 or more years preferred experience as a Clinical Documentation Specialist
• 3-5 years preferred supervisory experience

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.
• Completes concurrent secondary reviews of targeted patient populations to identify missed opportunities and accurate selection of principal diagnosis.
• Acts as liaison between the Coding Department and the Clinical Documentation Specialist to reconcile discrepancies in DRG assignment.
• Analyzes and interprets clinical data to identify gaps, inconsistencies, and/or opportunities for improvement in the clinical documentation and appropriately query the provider using a concurrent or retrospective query process.
• Follow up to ensure queries are answered.
• Assigns the appropriate DRG, MCCs and CCs to each record reviewed.
• Organizes and performs work responsibilities effectively and efficiently.
• Maintains strict patient confidentiality, adhering to HIPPA guidelines.
• Demonstrates standards of performance (ownership, teamwork, communication, compassion) that support patient satisfaction and principles of service excellence.
• Performs other duties as assigned.

Benefits

• Opportunity to be part of an organizational culture that supports not only exceptional patient care but also the well-being and professional growth of our employees.
• Contributions are valued, growth is nurtured, and success is celebrated.

What This Job Offers

• Job Type: Full-time
• Career Level: Manager
• Education Level: Associate degree