The Manager of Clinical Documentation Improvement (CDI) leads the enterprise CDI program to ensure accurate, complete, and compliant clinical documentation that reflects the true severity of illness, risk of mortality, and quality of care delivered. This leader oversees CDI workflows across inpatient and outpatient settings, partners closely with Coding, HIM, Revenue Cycle, Quality, and Medical Staff, and drives performance in metrics tied to case mix index (CMI), query response rates, DRG accuracy, severity capture, and publicly reported quality measures. The role is accountable for program strategy, team development, operational excellence, and alignment with organizational goals.
ResponsibilitiesThis is not an exhaustive statement of duties, responsibilities, or requirements. Employees will be required to perform any job, with related instruction given by their supervisor, subject to reasonable accommodation.
Program Leadership and Strategy
o Develop and execute the CDI strategy across service lines; set goals, KPIs, and dashboards tied to financial integrity and quality outcomes.
o Lead daily operations for CDI (worklists, prioritization, query standards, escalation pathways, coverage models, and service levels).
o Standardize policies, procedures, and documentation guidelines; ensure alignment with coding guidelines (ICD-10-CM/PCS), CMS, and payer requirements.
Clinical and Coding Collaboration
o Partner with Coding/HIM to optimize MS-DRG and APR-DRG accuracy, principal diagnosis selection, CC/MCC capture, and denials mitigation.
o Collaborate with Quality and Risk to enhance documentation supporting PSI/HAC exclusions, risk adjustment, and public reporting (e.g., CMS Stars, Leapfrog, Vizient).
o Build strong physician relationships, lead physician education, service line rounds, and specialty documentation initiatives.
People Leadership
o Manage and develop CDI staff (CDI specialists, leads, educators, auditors); oversee hiring, onboarding, training, competency assessments, and performance evaluations.
o Foster a culture of accountability, continuous improvement, and interprofessional collaboration.
Technology and Analytics
o Optimize Epic (e.g., Notes, Problem List, SmartTools, CDI workqueues, reporting).
o Use data to drive decision-making—monitor CMI, query response/agree rates, SOI/ROM, HACs and PSIs, O/E Mortality, length of stay (LOS) alignment, PEPPER/PSI/HAC trends, and denial patterns.
o Partner with IT/Analytics to develop actionable dashboards and root cause analyses.
Compliance and Quality
o Ensure CDI practices comply with AHIMA/ACDIS standards, CMS regulations, and organizational policies.
o Maintain documentation integrity and support clinical validation and audit readiness.
o Lead internal audits and implement corrective actions; track outcomes and sustain improvements.
Financial & Operational Performance
o Measure and report program impact (e.g., net revenue lift, DRG shifts, severity capture, denial avoidance).
o Steward resources—budget planning, productivity standards, and vendor management.
QualificationsYEARS OF RELATED WORK EXPERIENCE
Minimum: 5 years of progressive CDI experience in an acute care setting and 3 years of leadership experience in a health system.
Preferred: At least 5 years in CDI leadership or supervisory role in a health system. CDI Ambulatory experience.
All job qualifications listed indicate the minimum level necessary to perform this job proficiently.
LEVEL OF EDUCATION
Minimum: Bachelor’s Degree or higher in Nursing, Health Information Management or related field.
Preferred: Master’s degree in a related field.
CERTIFICATIONS, LICENSES, REGISTRATIONS
Minimum: Current RN license or RHIT (Registered Health Information Technician) or RHIA (Registered Health Information Administrator) In addition to RN, RHIT, or RHIA must also posses
CCDS – Certified Clinical Documentation Specialist (ACDIS) or CDIP – Certified Documentation Integrity Practitioner (AHIMA)
Preferred: Current RN License and CCDS or CDIP Certification
TECHNICAL REQUIREMENTS
Minimum: Inpatient experience in Epic. MS Office skills, including intermediate excel experience. Broad knowledge of Medicare guidelines.
Preferred: Intermediate MS Office skills, experience with Epic CDI software and clinical informatics.
YEARS OF RELATED WORK EXPERIENCE
Minimum: 5 years of progressive CDI experience in an acute care setting and 3 years of leadership experience in a health system.
Preferred: At least 5 years in CDI leadership or supervisory role in a health system. CDI Ambulatory experience.
KNOWLEDGE, SKILLS, and ABILITIES
All knowledge, skills, and abilities listed indicate the minimum level deemed necessary to perform this job proficiently.
PROBLEM SOLVING AND DECISION MAKING
Strong critical thinking and analytical skills. Ability to identify the trends and offer solutions.
INTERPERSONAL SKILLS
Assertive personality traits to facilitate ongoing physician communication. Ability to work independently in a time-oriented environment.
COMMUNICATION SKILLS
Excellent written and verbal communication skills; ability to write concisely and effectively when communicating with providers.
OTHER
Ability to develop material and give presentations to groups and committees as required
About UsTop Skills
What We Do
Mission Statement: To provide superior health care for and improve the health of our communities through a commitment to our core values of excellence, integrity, and compassion.
Founded in 1888, the not-for-profit Santa Barbara Cottage Hospital has been serving the community for more than 125 years. Cottage Health, formed in 1996 as the not-for-profit parent organization of Santa Barbara Cottage Hospital and its affiliated Cottage Children’s Medical Center, Cottage Rehabilitation Hospital, Goleta Valley Cottage Hospital, and Santa Ynez Valley Cottage Hospital, is guided by a volunteer board of directors from the greater Santa Barbara community and provides the residents of the Central and South Coast with exemplary health care, continuous improvements in medical practice, and a commitment to our communities.
