Director of Clinical Documentation Improvement and SLR

Main Line Health, Inc.; Newtown Square (Delaware County); On-site; USD 140,000 - 220,000; Full time

Job summary

Main Line Health, Inc. seeks a Director of Clinical Documentation Improvement and Second Level Review to provide system-wide CDI and SLR leadership.

The role oversees documentation integrity, DRG validation, and compliance while engaging physicians and collaborating with executive leaders across Revenue Cycle, Quality, and Compliance. Responsibilities include developing strategies, guiding multi-site CDI programs, and sustaining high-quality documentation to support quality metrics and

Qualifications

• Minimum seven to ten years of progressive leadership experience in Clinical Documentation Improvement, Health Information Management, Coding, Revenue Cycle, or Clinical Quality.
• Expertise in ICD-10-CM/PCS coding and DRG systems, with a focus on quality reporting and compliance.

Responsibilities

• Provide system-wide CDI and SLR leadership, strategy, and standards.
• Oversee concurrent and retrospective CDI reviews for accuracy and acuity.
• Lead post-discharge SLR processes for correct coding and DRG validation.
• Ensure regulatory compliance and manage audits and corrective actions.
• Engage physicians with documentation education and best practices.
• Collaborate with Revenue Cycle, Quality, Compliance, and executive leaders.

Skills

Leadership experience

ICD-10-CM/PCS knowledge

MS-DRGs/APR-DRGs knowledge

Regulatory/compliance knowledge

Executive-level communication

Physician engagement

Education

Bachelor's degree

Master's degree preferred

Job 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

• Leads CDI and SLR strategy, goals, standards, and system-wide initiatives.
• Serves as a subject matter expert for documentation integrity, quality reporting, reimbursement, and compliance

Clinical Documentation Improvement Oversight

• Oversees concurrent and retrospective CDI reviews to ensure documentation reflects acuity, SOI/ROM, medical necessity, and resource utilization.
• Leads improvement efforts focused on documentation accuracy, physician engagement, query compliance, and outcomes.

Second Level Review Oversight

• Leads post-discharge SLR processes for accurate code assignment, DRG validation, SOI/ROM assignment, and quality data integrity.
• Establishes focused review methodologies for high-risk, high-volume, and high-impact DRGs and diagnoses.

Quality, Regulatory, and Compliance Management

• Ensures compliance with federal, state, payer, and accreditation requirements related to documentation and coding.
• Directs audits, external review responses, corrective action plans, and compliance risk mitigation strategies.

Physician Engagement and Education

• Oversees physician and provider documentation education strategies.

Leadership and Talent Development

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

Collaboration and Organizational Partnerships

• 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