CDI Program Manager — Clinical Documentation Leader

Cape Fear Valley Health; Fayetteville (NC); On-site; USD 80,000 - 100,000; Full time

Job summary

Cape Fear Valley Health is seeking a Manager Clinical Documentation Specialist to lead the CDI program. The role coordinates daily CDS workflows and educates physicians, nursing staff, and health information management teams to ensure accurate documentation that supports appropriate reimbursement.

Responsibilities include mentoring new hires, reviewing program outcomes, and collaborating with coding and statistics leadership to align documentation with DRG requirements.

Qualifications

• Active RN licensure in North Carolina or compact state.
• Must maintain proficiency in clinical documentation standards.
• Certification requirements to be completed within 1 year of hire.

Responsibilities

• Oversee and coordinate CDS processes for daily workflow efficiency.
• Serve as preceptor and provide education and training for new hires.
• Review performance reports on the CDMP program from multiple perspectives.
• Identify educational needs for medical staff through CDIS reviews.
• Coordinate ongoing education for physicians on documentation improvement opportunities.
• Assist with training internal customers on documentation, coding and reimbursement.
• Identify principal diagnosis and CCs to reflect severity of illness per regulations.
• Facilitate modifications to documentation supporting DRG-based reimbursement.
• Consult with physicians to clarify information and present opportunities for documentation improvement.
• Review charts with Senior Coding Specialist and leadership when needed.
• Perform other duties as assigned.

Skills

CDI/CDIS knowledge

Critical care experience

Nursing licensure

Communication skills

Education

Associate’s degree in Nursing

Bachelor’s degree in Nursing preferred

Current NC RN license

CCDS/CDIP certification or within 1 year

Tools

EHR systems

Job description

Cape Fear Valley Health is seeking a Manager Clinical Documentation Specialist to lead the CDI program. The role coordinates daily CDS workflows and educates physicians, nursing staff, and health information management teams to ensure accurate documentation that supports appropriate reimbursement.

Responsibilities include mentoring new hires, reviewing program outcomes, and collaborating with coding and statistics leadership to align documentation with DRG requirements.