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Job description
Fusion 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 & Experience
Candidates may qualify under one of the following pathways:
Option 1 – Nursing Background
Graduate of an accredited school of nursing
Minimum five (5) years of clinical nursing experience
Three (3) years of CDI experience
Two (2) years of CDI leadership experience
Option 2 – International Medical Graduate
International MD with five (5) years of acute care experience
One (1) year of CDI experience
Two (2) years of CDI leadership experience
Option 3 – Health Information Management Background
Bachelor’s degree (or equivalent) in Health Information Management or Health Information Technology
Four (4) years of professional coding and abstracting experience in an acute care hospital
Two (2) years of CDI leadership experience
Required Certifications
Certification requirements vary by pathway:
Nursing Pathway
Active Registered Nurse license
One of the following: Certified Clinical Documentation Specialist (CCDS)
Certified Clinical Documentation Specialist–Outpatient (CCDS-O)
Certified Documentation Improvement Practitioner (CDIP)
Physician or HIM Pathway
One coding credential such as: CCS, RHIT, or RHIA
CPC or CPC-P
AND one CDI credential: CDIP, CCDS, or CCDS-O
Key Knowledge Areas
Reimbursement methodologies and coding guidelines
MS-DRGs and APR-DRGs
Severity of Illness (SOI) and Risk of Mortality (ROM)
Medical necessity, quality measures, and length-of-stay metrics
Hospital-acquired conditions (HACs) and patient safety indicators (PSIs)
Disease pathophysiology and pharmacology
Clinical documentation improvement practices
Regulatory standards and compliance requirements
Supervisory principles and operational management
Patient rights, safety practices, infection control, and emergency procedures
Core Competencies
Team leadership and staff development
Oversight of concurrent query processes
Data analysis and trend identification
Process design, implementation, and performance evaluation
Budget and staffing plan development
Chart review and clinical documentation interpretation
Regulatory interpretation and education delivery
Investigative interviewing and conflict resolution
Professional communication across interdisciplinary teams
Strong critical thinking and problem-solving skills
Ability to maintain strict confidentiality
This 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.
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Worksite address
las vegas, NV, 89105, US
Who can apply
Review the original listing for work authorization, qualifications and employer requirements.