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Manager of CDI (Clinical Documentation Improvement)

Company: Florida Head Hunters LLC
Location: Santa Ana
Posted on: May 27, 2023

Job Description:

Manager of CDI (Clinical Documentation Improvement)- Santa Ana, CA Direct Hire

Job #: 23-00524

Position Type: Direct Placement

Location: Santa Ana, CA, United States

Onsite Flexibility: All Onsite

Job Description

Location: Central Business Office

Job Title: Manager of CDI (Clinical Documentation Improvement)

Reports to: Corporate Senior Director, Clinical Integration


The Manager Clinical Documentation Improvement (CDI) has the overall responsibility for the management of the CDI Specialists and Program, which includes recruiting, hiring, training, mentoring and performance management CDI. Position facilitates the structure, process, oversight and accountability of organization documentation improvement, and health data collection activities to ensure accurate provider documentation and optimal reporting and reimbursement of health care services. Develops and implements strategic communication and education programs for CDI and its operations. Assists with denial responses if submitted for DRG. Assists with OSHPD reporting for all OC hospitals. Assumes primary responsibility for DRG optimization, primary role in assisting medical staff members with improving quality of documentation and serves as a reimbursement coding mentor. Participates in chart review projects as assigned.



Establishes policies and implements changes for and to enhance reimbursement coding outcomes.
Evaluates the effectiveness of coding personnel and processes.
Performs review, monitors, and makes effective change/corrections in reimbursement codes as applied to financial reports.
Instructional approach and management of Coding and CDI personnel.
Maintain confidentially, always protecting patient information: minimum information necessary to those with right and need to know.
Conduct a thorough review of the documentation available in the record, and accurately assign the appropriate principle and secondary, diagnosis and procedures.
Apply Current Procedural Terminology (CPT) coding convention & general guidelines published by the American Medical Association (AMA) for surgical and diagnostic procedure coding.
Follow coding guidelines as specified by AHA Coding Clinic and hospital policy. Commit to code assignment and data reporting in an unbiased, honest, and ethical manner.
Abstract patient data correctly and accurately complete all required elements in the electronic information system. Follow department policy and UHDDS abstracting guidelines, facilitating a positive outcome in the OSHPD error reports.
Ensure all pertinent documentation is available in the record for final coding and abstracting.
Discrepancies identified upon review of the medical record, for example in the content and quality of the transcribed report, are addressed appropriately.
Consult with medical staff members when necessary, for purposes of clarification of diagnoses and/or procedures.
Queries are formulated well; are clear, concise, and affect efficient assistance to the medical staff member for timely and accurate query response, complete documentation, and final coding.
Perform as a liaison, assisting medical staff members through education and feedback to improve the quality of documentation within the body of the medical record.
Follow department policy for prioritization of records to be coded, including STAT requests.
Consistently update coding status in the abstract module. Monitor un-coded records, taking initiative to resolve any issues and ensure timely abstracting and coding of data.
Serve as a role model and provide mentorship, assisting in the professional development of the Coder staff members.
Effective communication: writes and speaks clearly and concisely, affecting positive and efficient assistance to all requestors.
Perform required tasks and other duties as assigned, while maintaining a positive attitude.
Completes job duties in accordance with productivity requirements and quality standards.
Promptly report equipment malfunctions to the appropriate personnel to order service as needed.
Inventory supplies needed to perform job duties and place order on a regular basis to always ensure an adequate supply.
Initiate & participate in required and voluntary continuing education opportunities, enhancing professional growth and maintaining CEU's required for certification and/or by department policy.
Maintains current AHIMA certification.
Other duties as assigned or required.


Minimum five (3) years coding systems experience within a hospital setting; two (2) years supervisory experience required.
Certification or license as a Certified Coding Specialist (C.C.S.) required.
Successful completion of or current enrolment in a program for certification as a Certified Coding Specialist (C.C.S.), Registered Health Information Technician (R.H.I.T.), or Registered Health Information Administrator (R.H.I.A.); preferred.


Knowledge of compliance and regulatory requirements and IS and Health Information Systems.
Use of an encoder software product for code assignment in an acute care setting; preferred.
Knowledge of CPT, DRG, APC, and ICD-10 CM and PCS coding guidelines required.
Successful completion of college level courses in anatomy, physiology, medical terminology, and coding
Experience in managing Clinical Documentation Improvement Specialists, in its relationship to clinical documentation.
Experience with McKesson Intelligent Coding (Charging) application desirable


Body Positions: Sitting and standing for prolonged periods.
Body Movements: Arm and hand dexterity.
Body Senses: Must have command of close and distant sight, color perception and hearing.
Strength: Ability to lift and move up to 25-pounds.

Working Environment:

Work in an office, where the climate is controlled.
OSHA exposure category: II
Category I - Position includes tasks that involve exposure to Blood-borne Pathogens.
Category II - Position includes tasks that do not have exposure to Blood-borne Pathogens, however employment may require unplanned Category I tasks.
Category III - Positions includes tasks that do not involve exposure to Blood-borne Pathogens. This position would not be required to perform Category I tasks.

Keywords: Florida Head Hunters LLC, Santa Ana , Manager of CDI (Clinical Documentation Improvement), Healthcare , Santa Ana, California

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