Clinical Documentation Specialist Manager

Job Overview We are seeking a dynamic and experienced Clinical Documentation Specialist Manager to lead our clinical documentation improvement initiatives across diverse healthcare settings. In this pivotal role, you will oversee a team dedicated to enhancing the accuracy, completeness, and quality of medical documentation to support optimal patient care, compliance, and reimbursement. Your leadership will ensure adherence to industry standards such as NCQA and Medicare regulations while fostering continuous improvement in clinical documentation practices. This position offers an exciting opportunity to influence clinical outcomes, streamline documentation workflows, and elevate the overall quality of healthcare delivery. Responsibilities Lead and manage a team of clinical documentation specialists, providing mentorship, training, and performance evaluations to promote professional growth and operational excellence. Develop and implement comprehensive clinical documentation improvement strategies aligned with organizational goals and regulatory standards. Collaborate with physicians, nurses, coding professionals, and case managers to ensure accurate capture of diagnoses, procedures, and patient care activities within electronic health record (EHR) systems such as Epic, Cerner, Athenahealth, or eClinicalWorks. Review medical records for completeness and accuracy, ensuring compliance with

HIPAA, NCQA

standards, CMS guidelines (including

ICD-10/ICD-9

coding), and other regulatory requirements. Oversee utilization review and management processes for inpatient, outpatient, ICU, PICU (Pediatric Intensive Care Unit), Level I/II trauma centers, and specialty areas like hospice care or emergency medicine. Monitor key performance metrics related to clinical documentation quality, DRG validation, case mix index (CMI), and reimbursement accuracy; implement corrective actions as needed. Facilitate ongoing education for clinical staff on medical terminology, anatomy and physiology knowledge, CPT coding procedures, ICD coding updates, and documentation best practices to improve overall documentation integrity. Skills Extensive experience with EMR/EHR systems such as Epic, Cerner, Athenahealth or eClinicalWorks; proficiency in navigating complex clinical documentation workflows. Strong knowledge of managed care processes including Medicare/Medicaid regulations and utilization management protocols. Demonstrated expertise in critical care environments including ICU, PICU, trauma centers (Level I/II), emergency medicine or inpatient units; familiarity with discharge planning and hospice care processes. Proficiency in medical coding (ICD-10/ICD-9/DRG/CPT) along with a solid understanding of medical records management and health information technology standards. In-depth understanding of medical terminology, anatomy & physiology principles relevant to diverse specialties such as primary care, pediatrics or outpatient clinics. Ability to lead process improvements aligned with NCQA standards while ensuring compliance with HIPAA regulations governing patient confidentiality. Excellent communication skills for collaborating across multidisciplinary teams including nursing staff with hospital or nursing home experience or those working in Level I trauma centers or outpatient clinics. Join us in shaping the future of healthcare documentation! This role offers an engaging environment where your leadership directly impacts patient safety, operational efficiency, and revenue cycle integrity—all while supporting your professional growth in a fast-paced healthcare setting.

Pay:

$90,584.00 - $144,934.00 per year

Benefits:

401(k) Dental insurance Health insurance Life insurance Paid time off Vision insurance

Experience:

Acute care: 5 years (Preferred) Clinical Documentation Improvement (CDI): 3 years (Preferred) clinical documentation leadership: 3 years (Preferred)

Work Location:

In person