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Clinical Documentation Improvement Manager
Mount Sinai Medical Center

Location: Miami Beach, Florida
Work Setting: Hospital
Job Function:
CDI Specialist, Compliance
Job Type:


Clinical Documentation Improvement Manager
As Mount Sinai continues to grow so does our legacy of caring.

Mount Sinai Medical Center is proud to be South Florida’s hospital of choice for great medicine. With more than 4000 employees. 500 volunteers. 670 beds. 26 operating suites and more than 650 physicians and 950 nurses. Mount Sinai is South Florida’s largest private independent not-for-profit teaching hospital.

It takes the contribution of many individuals to make Mount Sinai the world-class institution it is today. As a team we have focused our efforts on assuring that our patients receive high quality medical care. We’re looking for motivated professionals who seek the challenge and stimulation of working in an academic medical center with an international reputation.

Job Description

The Clinical Documentation Improvement (CDI) Manager reports to a Director within a specific division of the organization. The manager has overall responsibility for the daily planning, work scheduling and coordination, and operational performance of the defined Clinical Documentation Improvement (CDI) program. The manager retains 24-hour responsibility, but may utilize supervisory staff to operationalize activities. Delegates, supervises personnel, solves problems, makes decisions and develops systems and processes for successful integration and implementation. Participates in interviewing, hiring, scheduling, training and evaluation of staff. Ensures the quality, consistency and timeliness of the facility coding and health record documentation comply with federal and state regulations. Independently carries out and is accountable for daily operations and other assigned activities. Seeks guidance from the Director and/or upper management for unusual or unanticipated circumstances that require deviation from policy/practice or allocation of funds to resolve. Performs other duties as assigned.

Manages the activities of the Clinical Documentation Improvement (CDI) department. Facilitates modifications to clinical documentation to ensure accurate depiction of the level of clinical services and patient severity through extensive concurrent interaction with physicians, nursing staff and other caregivers, case management and medical records coding staff.

Responsibilities Include:

  • Ensures clinical documentation, including modifications, accurately reflect the level of service rendered and severity of illness (in compliance with government and other regulations) for all patients.
  • Oversees a system to identify admissions with specific diagnosis / DRG classifications or other categories of admissions.
  • Ensures chart review within 48-72 hours of admission to meet criteria.
  • Ensures periodic documentation review with cases that have a length of stay greater than 3 days.
  • Ensures follow up reviews of clinical documentation are conducted by CDS staff to evaluate whether issues discussed and clarified with the physician have been recorded in the patient’s chart.
  • Ensures recommendation of possible refinement of principal diagnosis based on Clinical data on admission and concurrently during the hospital stay to facilitate appropriate DRG assignment.
  • Interacts with physician regarding documentation appropriate to diagnosis and support appropriate levels of severity of illness and risk of mortality.
  • Monitors CDI performance regularly by way of CDI software and performs routine query audits to ensure compliance.
  • Serves as a resource to Physicians / Case Managers and other key professional staff in matters relating to published DRG information.
  • Works with medical records, finance and physician groups to develop systems to facilitate complete documentation for data reporting purposes.
  • Develops and monitors strategic operating goals, objectives and budget; and reports operational performance, justification and/or corrective action.
  • Develops and manages direct reports; and oversees the development and management of indirect reports.
  • Builds and maintains productive inter/intra departmental and vendor work relationships to optimize operations.
  • Oversees compliance with government and agency regulations.
  • Performs related duties, as required.

Required Qualifications

  • Current license to practice as a Registered Professional Nurse.
  • Minimum of seven (7) years of progressive experience in an acute care setting.
  • Previous experience in chart review, required.
  • Regulatory background and DRG reimbursement knowledge, preferred.
  • Ability to communicate effectively with physicians and other clinical professional staff.

Education Qualifications

  • Bachelor’s Degree in Nursing or related field, required. Master’s Degree, preferred.


We offer:

  • An excellent team focused work environment with opportunity for professional growth
  • Competitive salary with bonus potential
  • Savings plan with company match
  • A variety of health dental and vision plans
  • On-site childcare, tuition reimbursement and much more!

Instructions for Resume Submission

Please submit resume to: or apply online.

Apply Online:

Posted: October 17, 2019 at 4:14 PM
Post ID: 44059

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