Director of Clinical Documentation Improvement and SLR

Main Line Health; Newtown (PA); On-site; USD 114,000 - 176,000; Full time

Benefits offered by this job

Tuition Reimbursement (up to $6,000/yr

Flexible PTO

Free employee parking

Job summary

Main Line Health is seeking a Director of Clinical Documentation Improvement and Second Level Review to provide system-wide CDI/SLR leadership. You will guide strategy, standardize reviews, and ensure documentation supports quality outcomes, reimbursement integrity, and regulatory compliance.

The role requires seven to ten years of leadership in CDI, HIM, coding, or related fields, with multi-site program experience and strong knowledge of ICD-10-CM/PCS, DRGs, and risk adjustment.

Qualifications

• Bachelor’s degree required.
• Master’s degree preferred.
• RHIA/RHIT/CDDS/CDIP/RN or equivalent certification required.
• CCS certification preferred.
• Experience leading multi-site CDI programs.
• Strong knowledge of ICD-10-CM/PCS, DRGs, quality reporting, risk adjustment, reimbursement, and regulatory requirements.

Responsibilities

• Leads CDI and SLR strategy, goals, standards, and system-wide initiatives.
• Oversees concurrent and retrospective CDI reviews to ensure documentation reflects acuity, medical necessity, and resource utilization.
• Directs post-discharge SLR processes for accurate code assignment, DRG validation, and data integrity.
• Ensures compliance with federal, state, payer, and accreditation requirements.
• Oversees physician and provider documentation education strategies.
• Supports coaching, mentoring, succession planning, and a culture of accountability.
• Collaborates with Revenue Cycle, Quality, Medical Staff, Compliance, and executives.

Skills

Strategic Leadership

Program Oversight

Clinical Documentation Improvement

Regulatory Compliance

Executive Presentation

Physician Engagement

Collaboration

Talent Development

Education

Bachelor’s degree

Master’s degree in Health Administration / Health Informatics

RHIA

RHIT

CCDS

CDIP

RN

CCS

Job description

Description:

Could you be our next Director of Clinical Documentation Improvement and Second Level Review?

++Why work as a Director of Clinical Documentation Improvement and Second Level Review with Main Line Health?++

Make an Impact! The Director of Clinical Documentation Improvement (CDI) and Second Level Review (SLR) provides system-wide leadership for clinical documentation integrity and post-discharge review operations. This role ensures clinical documentation accurately supports quality outcomes, SOI/ROM, patient safety indicators, reimbursement integrity, and regulatory compliance. Responsibilities include:

• Strategic Leadership and Program Oversight

o Leads CDI and SLR strategy, goals, standards, and system-wide initiatives.

o Serves as a subject matter expert for documentation integrity, quality reporting, reimbursement, and compliance

• Clinical Documentation Improvement Oversight

o Oversees concurrent and retrospective CDI reviews to ensure documentation reflects acuity, SOI/ROM, medical necessity, and resource utilization.

o Leads improvement efforts focused on documentation accuracy, physician engagement, query compliance, and outcomes.

• Second Level Review Oversight

o Leads post-discharge SLR processes for accurate code assignment, DRG validation, SOI/ROM assignment, and quality data integrity.

o Establishes focused review methodologies for high-risk, high-volume, and high-impact DRGs and diagnoses.

• Quality, Regulatory, and Compliance Management

o Ensures compliance with federal, state, payer, and accreditation requirements related to documentation and coding.

o Directs audits, external review responses, corrective action plans, and compliance risk mitigation strategies.

• Physician Engagement and Education

o Oversees physician and provider documentation education strategies.

• Leadership and Talent Development

o Supports coaching, mentoring, succession planning, and a culture of accountability and collaboration

• Collaboration and Organizational Partnerships

o Collaborates with Revenue Cycle, Quality, Medical Staff, Compliance, Case Management, Utilization Review, Finance, Information Systems, and executive leaders.

Develop and Grow your Career! Invest in furthering your education through seeking certifications or advanced degrees by taking advantage of our Tuition Reimbursement! This position is eligible for up to $6,000 per year based upon your Full or Part Time status.

Join the Team! Like our patients, the Main Line Health Family encompasses a wide range of backgrounds and abilities. Just as each of our patients requires a personalized care plan, each of our employees, physicians, and volunteers, bring distinctive talents to Main Line Health. Regardless of our unique design, we all share a purpose: providing superior service and care.

Position-Specific Benefits include: This position is eligible for Main Line Health’s Flexible PTO program. With this, you have the freedom and flexibility to take paid time off as needed: no set number of days per year allotted to your position, and no wait period to begin using your Flexible PTO. We also offer a number of employee discounts to various activities, services, and vendors... And employee parking is always free!

Position: Director, HIM Revenue Cycle

Shift: M-F Days

++Experience:++

Minimum seven to ten years of progressive leadership experience in Clinical Documentation Improvement, Health Information Management, Coding, Revenue Cycle, or Clinical Quality

Demonstrated experience leading multi-site CDI programs

Strong knowledge of ICD-10-CM/PCS coding, MS-DRGs, APR-DRGs, quality reporting methodologies, risk adjustment, reimbursement systems, and regulatory compliance requirements

Experience presenting to executive leadership, physicians, and governing committees

++Education:++

Bachelor’s degree required.

Master’s degree in Health Administration, Business Administration, Nursing, Health Informatics, or related field preferred.

++Licensures/Certifications:++

RHIA, RHIT, CCDS, CDIP, RN, or equivalent certification required

CCS coding certification preferred

Additional Information

• Requisition ID: 82883
• Employee Status: Regular
• Schedule: Full-time
• Shift: Day Job
• Pay Range: $113,568.00 – $175,968.00
• Job Grade: 117