Regional Clinical Documentation Improvement Director

Job Summary

The Regional Director of Clinical Documentation Integrity (RDCDI) supports the organizations clinical documentation improvement (CDI) objectives by ensuring patient health records are complete, accurate, and aligned with clinical and operational standards. This role works closely with executive leaders and hospital teams to promote high-quality documentation that supports correct reimbursement, optimal quality outcomes, and enhanced communication among providers. The RDCDI also leads ongoing education, monitors CDI metrics, and develops action plans to address trends.

Responsibilities

Core Responsibilities

• Cross-train across all service lines.

• Develop and manage CDI functions and activities across assigned hospitals.

• Serve as the organizational subject matter expert for CDI, supporting internal initiatives.

• Perform initial, concurrent, and retrospective clinical reviews to ensure the DRG accurately reflects diagnoses and conditions after study.

• Identify and clarify POA indicators, HAI, HAC, and potential DRG shifts.

• Ensure accurate documentation supporting SOI/ROM and resource utilization.

• Review documentation for completeness and accuracy; provide ongoing education.

• Analyze clinical information to identify conflicting, incomplete, ambiguous, or inconsistent documentation and query providers for clarification.

• Utilize compliant written and verbal querying processes based on guidelines and policy.

• Track, trend, and report query rates, response rates, and outcomes.

• Collaborate with providers and staff to promote accurate documentation and correct negative trends.

• Provide CDI education in group or one-on-one settings, both remotely and onsite.

• Educate internal staff on clinical documentation and coding guidelines.

• Participate in Interdisciplinary Care Team meetings to identify CDI opportunities and reinforce expectations.

Principle Duties

• Maintain exceptional professionalism, courtesy, and communication.

• Uphold organizational mission, vision, and confidentiality standards.

• Adhere to all policies, procedures, and regulatory requirements.

• Comply with the Employee Code of Conduct and institutional guidelines.

Qualifications

• Education & Training:
  Completion of a clinical program (RN, LPN, RT, etc.) and/or a bachelors degree in Health Information Management or related field. RHIA or CCS certification preferred.

• Experience:
  At least 5 years of acute care experience with recent supervisory or management responsibilities.

• Preferred Certifications:
  CCDS or CDIP preferred; willingness to obtain CCDS or CDIP within 2.5 years of employment.

• Skills & Requirements:
  Current licensure and/or certification relevant to the clinical or HIM field.