Director of Clinical Documentation Improvement and SLR

Main Line Health • Newtown Square, PA

48d • Onsite

About The Position

The Director of Clinical Documentation Improvement (CDI) and Second Level Review (SLR) provides system-wide leadership for clinical documentation integrity and post-discharge review operations. This role ensures clinical documentation accurately supports quality outcomes, SOI/ROM, patient safety indicators, reimbursement integrity, and regulatory compliance.

Requirements

• Minimum seven to ten years of progressive leadership experience in Clinical Documentation Improvement, Health Information Management, Coding, Revenue Cycle, or Clinical Quality
• Demonstrated experience leading multi-site CDI programs
• Strong knowledge of ICD-10-CM/PCS coding, MS-DRGs, APR-DRGs, quality reporting methodologies, risk adjustment, reimbursement systems, and regulatory compliance requirements
• Experience presenting to executive leadership, physicians, and governing committees
• RHIA, RHIT, CCDS, CDIP, RN, or equivalent certification required

Nice To Haves

• Master's degree in Health Administration, Business Administration, Nursing, Health Informatics, or related field preferred.
• CCS coding certification preferred

Responsibilities

• Leads CDI and SLR strategy, goals, standards, and system-wide initiatives.
• Serves as a subject matter expert for documentation integrity, quality reporting, reimbursement, and compliance.
• Oversees concurrent and retrospective CDI reviews to ensure documentation reflects acuity, SOI/ROM, medical necessity, and resource utilization.
• Leads improvement efforts focused on documentation accuracy, physician engagement, query compliance, and outcomes.
• Leads post-discharge SLR processes for accurate code assignment, DRG validation, SOI/ROM assignment, and quality data integrity.
• Establishes focused review methodologies for high-risk, high-volume, and high-impact DRGs and diagnoses.
• Ensures compliance with federal, state, payer, and accreditation requirements related to documentation and coding.
• Directs audits, external review responses, corrective action plans, and compliance risk mitigation strategies.
• Oversees physician and provider documentation education strategies.
• Supports coaching, mentoring, succession planning, and a culture of accountability and collaboration.
• Collaborates with Revenue Cycle, Quality, Medical Staff, Compliance, Case Management, Utilization Review, Finance, Information Systems, and executive leaders.

Benefits

• Tuition Reimbursement (up to $6,000 per year based upon Full or Part Time status)
• Flexible PTO program
• Employee discounts to various activities, services, and vendors
• Free employee parking

What This Job Offers

• Job Type: Full-time
• Career Level: Director