Director Clinical Document Integrity

Socket.dev; Gainesville (FL); On-site; USD 170,000 - 250,000; Full time

Job summary

Socket.dev seeks a Director of Clinical Documentation Integrity to lead and standardize enterprise CDI programs across inpatient and ambulatory settings. You will partner with physicians, CM, UM, and Revenue Cycle to improve documentation quality, MS-DRG/HCC capture, and audit defensibility.

You will guide governance, drive provider engagement, and ensure compliant query practices while coaching clinical leaders toward measurable performance improvements.

Qualifications

• RN licensure with active status.
• CCDS is required.
• CCDS-O, CCS, CDIP, CDEO, CDEI or CRCR preferred.

Responsibilities

• Lead and govern enterprise CDI program across inpatient and ambulatory settings.
• Partner with physicians, service lines, CM, and Revenue Cycle for engagement and reporting.
• Drive improvement in documentation quality, MS-DRG and HCC capture, and audit defensibility.
• Coach clinical departments and faculty on compliant documentation and query practices.

Skills

CDI leadership

Executive communication

Cross-functional collaboration

Performance analytics

Coding & DRG mastery

HCC risk adjustment

Education

BSN

Master’s degree (related field)

Tools

Epic

Iodine

Interact

Job description

Overview

The Director of Clinical Documentation Integrity (CDI) provides enterprise-wide leadership for inpatient and ambulatory documentation integrity, including compliant query practices, standardized CDI workflows, and governance in partnership with Coding, Utilization Management (UM), Quality, and Compliance. This leader is accountable for operating a consistent CDI program that improves documentation quality, supports appropriate severity and risk capture (Medicare Severity Diagnosis-Related Groups (MS-DRGS) and Hierarchical Condition Categories (HCCs)), strengthens Case Mix Index (CMI) and audit defensibility, and reduces documentation-driven denials and rework. The Director partners with physicians, service line leaders, Case Management, and Revenue Cycle/Analytics teams to drive provider engagement, performance reporting, and enterprise-wide standardization.

Qualifications

Education

• Bachelor’s degree required (BSN)
• Master’s preferred (in a related field)

Experience

• Minimum of 5 to 7 years of progressive, direct experience as a CDI Specialist
• Minimum of 3 to 4 years of managerial, supervisory, or director-level experience, ideally within a large academic medical center or a complex medical hospital with proven team and talent development

License/Certification/Registration

• CCDS (required)
• RN (Active)
• CCDS-O (preferred)
• CCS (preferred)
• CDIP (preferred)
• CDEO (preferred)
• CDEI (preferred)
• CRCR (preferred)

Other Qualifications

• Cross-functional collaboration and conflict navigation
• Change leadership with continuous improvement mindset
• Executive-ready communication (written, verbal, facilitation)
• Strengthen influencing without authority in a matrixed health system environment
• Deep knowledge of Clinical Documentation Integrity (CDI) best practices and compliant query standards
• Comprehensive mastery of coding and DRG assignments, including both MS-DRG and APR-DRG methodologies and expertise in inpatient CDI workflows
• Strong reimbursement and coding acumen, including ICD-10-CM/PCS, Medicare Severity Diagnosis-Related Groups (MS-DRGs), and Case Mix Index (CMI) drivers
• Working knowledge of ambulatory documentation priorities, including E/M level selection and risk adjustment mechanisms such as Hierarchical Condition Categories (HCC) and risk capture
• The ability to impact and interpret hospital quality scores
• Practical working experience with Epic, combined with Iodine and Interact
• Ability to act as a trusted advisor to clinical departments and academic faculty, successfully coaching busy physicians and residents on compliant documentation
• Proven success in establishing a Center of Excellence by partnering with HIM and coding leadership to align training and quality assurance
• Documentation risk and audit-readiness knowledge, including denial themes and defensibility expectations
• Advanced analytical capability in trend analysis, root-cause thinking, and performance metric development/interpretation