Clinical Documentation Manager

Clinical Documentation Manager

Fusion HCR is hiring! Direct hire – Clinical Documentation Manager, this is an onsite opportunity, working with our client in Acute Healthcare.

Our client, a large healthcare organization, is seeking an experienced Clinical Documentation Improvement (CDI) Manager to drive documentation accuracy, regulatory compliance, and clinical integrity across acute care services.

This role is responsible for identifying documentation improvement opportunities related to ICD-10, UHDDS, and CMS guidelines. The leader provides oversight of concurrent query processes, supports daily CDI operations, and collaborates closely with physicians, Advanced Practice Professionals, HIM, Coding, Quality, and Revenue Cycle teams to ensure documentation accurately reflects the patient's true clinical condition.

The position uses data analysis and trend monitoring to develop sustainable process improvements that enhance documentation quality, reimbursement integrity, and regulatory compliance. This leader applies clinical expertise and CDI best practices while supporting the mission and standards of the organization.

Education & Experience

Candidates may qualify under one of the following pathways:

Option 1 – Nursing Background

• Graduate of an accredited school of nursing
• Minimum five (5) years of clinical nursing experience
• Three (3) years of CDI experience
• Two (2) years of CDI leadership experience

Option 2 – International Medical Graduate

• International MD with five (5) years of acute care experience
• One (1) year of CDI experience
• Two (2) years of CDI leadership experience

Option 3 – Health Information Management Background

• Bachelor's degree (or equivalent) in Health Information Management or Health Information Technology
• Four (4) years of professional coding and abstracting experience in an acute care hospital
• Two (2) years of CDI leadership experience

Required Certifications

Certification requirements vary by pathway:

Nursing Pathway

• Active Registered Nurse license
• One of the following:
• Certified Clinical Documentation Specialist (CCDS)
• Certified Clinical Documentation Specialist–Outpatient (CCDS-O)
• Certified Documentation Improvement Practitioner (CDIP)

Physician or HIM Pathway

• One coding credential such as:
• CCS, RHIT, or RHIA
• CPC or CPC-P
• AND one CDI credential:
• CDIP, CCDS, or CCDS-O

Key Knowledge Areas

• Reimbursement methodologies and coding guidelines
• MS-DRGs and APR-DRGs
• Severity of Illness (SOI) and Risk of Mortality (ROM)
• Medical necessity, quality measures, and length-of-stay metrics
• Hospital-acquired conditions (HACs) and patient safety indicators (PSIs)
• Disease pathophysiology and pharmacology
• Clinical documentation improvement practices
• Regulatory standards and compliance requirements
• Supervisory principles and operational management
• Patient rights, safety practices, infection control, and emergency procedures

Core Competencies

• Team leadership and staff development
• Oversight of concurrent query processes
• Data analysis and trend identification
• Process design, implementation, and performance evaluation
• Budget and staffing plan development
• Chart review and clinical documentation interpretation
• Regulatory interpretation and education delivery
• Investigative interviewing and conflict resolution
• Professional communication across interdisciplinary teams
• Strong critical thinking and problem-solving skills
• Ability to maintain strict confidentiality

This leadership opportunity is ideal for a clinically experienced professional who thrives at the intersection of quality, compliance, and revenue integrity and is passionate about elevating documentation excellence across the organization.