Provides strategic and operational leadership for clinical documentation programs
Supports quality reporting, severity of illness and risk of mortality (SOI/ROM), value-based reimbursement, and risk-adjusted outcomes
Oversees CDI/CDE staff and conducts documentation audits
Ensures compliance with regulatory and risk‑based reimbursement requirements
Identifies documentation gaps and trends and drives continuous improvement initiatives
Promotes operational efficiency and documentation excellence across the organization
Collaborates closely with physicians, coding teams, and CDI/CDE advisors to enhance documentation quality
Develops and delivers targeted education on documentation best practices

Graduate of an accredited School of Nursing
5 years of clinical experience in an acute or ambulatory care setting
3-5 years of leading/managing a clinical documentation team
Current State Registered Nurse License
Excellent written, verbal, and interpersonal communication skills
Demonstrated leadership and team-building abilities
Strong analytical and critical-thinking skills
In-depth knowledge of clinical documentation requirements, ICD‑10‑CM coding guidelines, and risk‑adjustment methodologies
Ability to maintain current knowledge of regulatory requirements, industry trends, and emerging risk‑adjustment and documentation programs
Experience managing departmental operations
Strong organizational, planning, and time‑management skills
Proficiency with Microsoft Office applications and clinical documentation and coding tools

Quality & Risk Manager

Key skills