Manager (RN) - Clinical Documentation Management Program

Description

Management/Leadership
Req #: 37385

MaineHealth is seeking a dynamic and experienced Clinical Documentation Specialist (CDS) Manager to lead our dedicated team in ensuring the accuracy, completeness, and integrity of clinical documentation across the system. Reporting to the Director of Clinical Documentation Improvement, this role oversees a team of CDS professionals, currently comprising twenty-four direct reports, who collaborate with providers and coding teams to optimize clinical documentation for quality reporting, reimbursement, and patient care outcomes. The CDS Manager plays a critical role in driving compliance, education, and performance improvement initiatives within the department. Our ideal candidate is a strong communicator and leader with deep knowledge of CDI principles, healthcare coding, and clinical practice. They bring a strategic mindset, proven management experience, and a passion for advancing excellence in patient documentation and care.

This position normally scheduled Monday - Friday and is based in our Scarborough office with hybrid flexibility.

Summary:
The Manager of Clinical Documentation Improvement, "CDI", brings subject matter expertise related to clinical documentation improvement, and works closely with regional and site specific executive leadership and medical staff throughout Maine Health to implement and manage a concurrent CDI program. The CDI manager executes programs which capture appropriate clinical documentation through extensive interaction with physicians, nursing leadership and staff, other patient care givers, and HIM coding staff to ensure appropriate reimbursement and clinical data quality measures for the level of services provided to patients. The CDI manager ensures the clinical information used in profiling and reporting outcomes is complete and accurate. The CDI Manager will develop training sessions and in-services in collaboration with the Coding Director, facilitating appropriate clinical documentation to ensure acuity and severity of illness are accurately reflected in the patient's medical record. The CDI Manager makes available assessment and feedback of physician documentation compliance, as well as the need for process improvement or change. In collaboration with the Coding Director, the CDI Manager ensures education for all members of the patient care team on an ongoing basis related to clinical documentation issues.

Required Minimum Knowledge, Skills, and Abilities (KSAs)

1. Education: Bachelor's degree in Nursing, Health Administration, or Education in a related field. Master's preferred.
2. License/Certifications: State of Maine Licensed, Registered Nurse. National certification in Clinical Documentation, CCDS from ACDIS.
3. Experience: Minimum of 5-8 year's of experience in clinical documentation improvement (CDI). Expertise in utilization management and Medicare regulations required. Prior Acute care RN experience.
4. Proficiencies: Advanced analytic skills. Strong organizational and prioritization skills. Collaboration with medical staff and executive leadership, presentation skills, and strong leadership skills.
5. Specialized Knowledge: General knowledge of coding guidelines, CMS regulations, and strong critical care clinical background.

If you have questions about this role, please contact tabor.badger@mainehealth.org