Clinical Documentation ManagerFusion 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 & ExperienceCandidates may qualify under one of the following pathways:Option 1 – Nursing BackgroundGraduate of an accredited school of nursingMinimum five (5) years of clinical nursing experienceThree (3) years of CDI experienceTwo (2) years of CDI leadership experienceOption 2 – International Medical GraduateInternational MD with five (5) years of acute care experienceOne (1) year of CDI experienceTwo (2) years of CDI leadership experienceOption 3 – Health Information Management BackgroundBachelor's degree (or equivalent) in Health Information Management or Health Information TechnologyFour (4) years of professional coding and abstracting experience in an acute care hospitalTwo (2) years of CDI leadership experienceRequired CertificationsCertification requirements vary by pathway:Nursing PathwayActive Registered Nurse licenseOne of the following:Certified Clinical Documentation Specialist (CCDS)Certified Clinical Documentation Specialist–Outpatient (CCDS-O)Certified Documentation Improvement Practitioner (CDIP)Physician or HIM PathwayOne coding credential such as:CCS, RHIT, or RHIACPC or CPC-PAND one CDI credential:CDIP, CCDS, or CCDS-OKey Knowledge AreasReimbursement methodologies and coding guidelinesMS-DRGs and APR-DRGsSeverity of Illness (SOI) and Risk of Mortality (ROM)Medical necessity, quality measures, and length-of-stay metricsHospital-acquired conditions (HACs) and patient safety indicators (PSIs)Disease pathophysiology and pharmacologyClinical documentation improvement practicesRegulatory standards and compliance requirementsSupervisory principles and operational managementPatient rights, safety practices, infection control, and emergency proceduresCore CompetenciesTeam leadership and staff developmentOversight of concurrent query processesData analysis and trend identificationProcess design, implementation, and performance evaluationBudget and staffing plan developmentChart review and clinical documentation interpretationRegulatory interpretation and education deliveryInvestigative interviewing and conflict resolutionProfessional communication across interdisciplinary teamsStrong critical thinking and problem-solving skillsAbility to maintain strict confidentialityThis 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.