Job Description

DESCRIPTION OF POSITION:

• The Clinical Documentation Improvement (CDI) Manager also has experience as a Second Level Reviewer , certified in CDI with a broad clinical knowledge base and understanding of DRG documentation requirements.
• Manage daily CDI operations and activities.
• Lead, coach and evaluate CDI specialist to ensure high performance and professional development.
• Conduct concurrent secondary and retrospective medical record review for defined patient populations to identify opportunities to improve accuracy of documentation; collaborating with Quality team, Case Managers and Coding department to assure documentation is clinically appropriate, accurately reflects the severity of illness for the patient, and is reflective of current CMS standards.

SUPERVISION: Reports directly to the Director of CDI

RESPONSIBILITIES AND DUTIES:

• 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.
• Advanced clinical expertise and extensive knowledge of complex disease processes with a broad clinical experience in an inpatient setting required.
• 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.

The above statements are only meant to be a representative summary of the major duties and responsibilities performed by incumbents of this job. The incumbents may be requested to perform job-related tasks other than those stated in this description.

Certification, Registration, or Licensure Required

• Registered Nurse/BSAN, RHIA, RHIT, or related clinical allied health degree required, or Physician Assistant (PA) preferred
• Licensure / Certifications: CCS, CCDS, or CDIP required
• Experience: Minimum of 5 years’ experience as a Clinical Documentation Specialist required, 7 or more years preferred.
• Minimum of 2 years supervisory experience required, 3-5 years preferred.

Physical Demands/Work Environment

• Work requires a variety of physical activities, including moving about within and outside of all hospital properties for long periods of time.
• Must be able to respond quickly and effectively to emergency and non-emergent situations.
• May be required to assist in controlling disorderly conduct or combative patients.
• Must be able to exchange accurate information with patient, family, peers and medical personnel.
• Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions

“Experience Memorial” is more than a slogan, it’s the care we provide our patients and it’s the commitment to our community and our team members. As a nationally certified Great Place to Work, at Lake Charles Memorial Health System you will have the opportunity to be a part of an organizational culture that supports not only exceptional patient care but also the well-being and professional growth of our employees. Join us and be a part of a team where your contributions are valued, your growth is nurtured, and your success is celebrated.

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