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Job Category:

Medical and Clinical Operations



Approximate Salary:

Not Specified

Position Type:

Full Time

Service Area Director - Clinical Documentation Improvement (15K sign-on bonus)

UHG - New York, New York

Posted: 12/13/2018

The Service Area Director, Clinical Documentation Improvement directs the activities of the Clinical Documentation Improvement (CDI) department. The selected candidate is responsible for providing CDI program oversight and day-to-day implementation of processes related to the concurrent review of the clinical documentation in the inpatient medical record of Optum 360 client (Dignity Health) patients at six hospitals across the Southern California service area.  This includes, but is not limited to, overall responsibility for the planning, administration, control and quality management of the CDI Department activities in addition to regular reporting of department progress and initiative to hospital leadership.


This position collaborates with providers and other healthcare team members to make improvements that result in accurate, comprehensive documentation that reflects completely, the clinical treatment, decisions, and diagnoses for the patient.  This position utilizes clinical expertise and clinical documentation improvement practices and facility specific tools for best practice and compliance with the mission / philosophy, standards, goals and core values of Optum 360.  The Service Area Director of CDI does not have patient care duties, does not have direct patient interactions, and has no role relative to patient care.


 The CDI Service Area Director is involved in the education of all phases of the Clinical Documentation Improvement process across a service area.   Provides ongoing Clinical Documentation Improvement education for physicians & new staff and new initiatives or identified areas of knowledge deficit.  Tracks and trends program compliance to determine areas of focus for educational opportunities.


*** This position will support the Southern California Service Area***

**Permanent location needed in the Los Angeles Area**


Primary Responsibilities:

  • Responsible for the operations, business, financial, and human resource needs of the CDI department
  • Plan daily operations of the department in conjunction with the Senior Director and participates in development of objectives to meet KPI’s
  • Direct and maintains adequate staffing and workflow to meet CDI needs
  • Monitor various reports and productivity to ensure that production standards and objectives are met in areas of responsibility
  • Lead the CDI program as demonstrated by assuming accountability for the ongoing success of the Clinical Documentation Program. Monitors CDI program and communicates with appropriate facility leadership regarding CDI key performance indicators (KPIs), and identifies and implements process changes to maintain and improve KPIs
  • Engage and consult with Physician Advisor and / or CMO to resolve provider issues regarding answering clarifications and participation in the clinical documentation improvement process.
  • Serves as a resource to Physicians / Case Managers and other key professional staff in matters relating to clinical documentation improvement & ICD-10
  • Works with medical records, quality, 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
  • Provide ongoing Clinical Documentation Improvement education for providers & new staff and new initiatives or identified areas of knowledge deficit.  Track and trend program compliance to determine areas of focus for educational opportunities
  • Design and implements education programs which provide education for CDIP staff
    • Develop and conduct ongoing CDIP education for new staff
    • Participate in ongoing education of staff
  • Communicate information effectively
    • Monthly reporting of CDI program progress / operations to hospital leadership
    • Responding to questions, concerns and requests promptly
    • Serving as a resource regarding, policies / procedures / practices
  • Identify areas of improvement / education through data collection, analysis, and reports.  Participate on committees and conduct studies as necessary to demonstrate improvement in clinical documentation processes
  • Interview, hire, provide leadership, counseling, training for employees in areas of responsibility
  • Ensure new employees are oriented and trained in all job functions
  • Perform counseling both verbal and written for employees requiring additional assistance as evidenced by communication in the personnel file
  • Provide consultation to providers and other clinical professionals, and leads implementation of changes that result in improvements in the patient care team’s ability to provide appropriate and timely treatment, communication regarding the patient’s condition, patient’s response to treatment, severity of illness, risk of mortality and treatment complexity

Required Qualifications:

  • Nurse (RN, NP), Physician (MD, DO, FMG), Physician Assistant (PA)
  • Graduate of a state approved RN program, BSN required (for nurse applicants)
  • Prior Leadership of people and projects
  • Minimum of 4 years of CDI experience in an acute in patient setting.
  • Minimum of 2 years of direct Management experience
  • CCDS or CDIP certification
  • Strong Analytical skills (with CDI metric related focus)
  • 3+ years of Excel proficiency
  • Strong written and spoken communication abilities

Preferred Qualifications:

  • CCS Certification
  • Excellent communication skills
  • Strong MS office skills
  • Strong ability to influence key stake holders

Health care isn't just changing. It's growing more complex every day. ICD-10 has replaced ICD-9. Affordable Care adds new challenges and financial constraints. Where does it all lead? Hospitals and health care organizations continue to adapt, and we are a vital part of their evolution. And that's what fueled these exciting new opportunities.

Optum360 is a dynamic new partnership formed by Dignity Health and Optum to combine our unique expertise. As part of the growing family of UnitedHealth Group, we'll leverage all our resources to bring financial clarity and a full suite of revenue management services to health care providers nationwide.

If you're looking for a better place to use your passion and your desire to drive change, this is the place to be. It's an opportunity to do your life's best work.(sm)


Diversity creates a healthier atmosphere: All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.


UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.



 Job Keywords: CDI, Leadership, Management, Analytics, Hospital


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