Lead Clinical Documentation Coordinator

Aiken Regional Medical Centers; Westcliff (SC); On-site; USD 85,000 - 110,000; Full time

Benefits offered by this job

Unlimited Employee Referral Bonus

Generous Paid Time Off

Excellent Medical, Dental, Vision and

Tuition/Certification Reimbursement

401(K) with company match

Job summary

Universal Health Services, a major healthcare provider, seeks a Lead Clinical Documentation Coordinator for its CDI program at Aiken Regional Medical Centers in South Carolina. You will lead the CDI team, coordinate physician education, and ensure documentation supports DRG and severity of illness criteria.

The role requires RN licensure in SC, CDI experience, and strong communication with clinicians. This position offers comprehensive benefits and opportunities within UHS.

Qualifications

• Graduate of nursing program; BSN preferred.
• Minimum of 5 years recent clinical experience in an acute care setting; Critical Care or Medical/Surgical preferred; 3–5 years inpatient coding and DRG guidelines experience.
• Must have knowledge of Medicare reimbursement system and coding guidelines; excellent written and verbal communication skills.
• RN license in SC and RHIA/RHIT/CCS preferred.

Responsibilities

• Manage the operations of the Clinical Documentation Improvement (CDI) program; supervise staff on a day-to-day basis.
• Serve as a super-user and trainer for the CDI program and all application software used to code/assign MS-DRG, APR-DRG, SOI, and ROM.
• Lead educational resource for internal customers on CDI program effectiveness and documentation requirements for DRG revenue assurance, compliance and quality outcomes.
• Oversee CDIS audits to ensure compliant and effective queries.
• Provide leadership and guidance, and manage the CDI team.
• Perform other duties as assigned.

Skills

Clinical Documentation

Clinical experience

Communication skills

Medicare coding knowledge

RN licensure

Education

BSN preferred

SC RN license included

Job description

Responsibilities

Lead Clinical Documentation Coordinator

Aiken Regional Medical Centers, located in Aiken, South Carolina, is a 273-bed acute care facility providing top quality and safe healthcare to the residents of Aiken and surrounding communities since 1917. Aiken Regional Medical Centers has been ranked a top hospital in South Carolina by the American Heart Association for its treatment of heart attack, heart failure and Stroke, and most recently, coronary artery disease.

Additionally, Aiken Regional provides comprehensive healthcare services such as behavioral health (Aurora Pavilion Behavioral Health), emergency medical care (main hospital and ER at Sweetwater), orthopedic surgeries, maternity, rehabilitation services(Hitchcock Rehabilitation Services), imaging, and wound care.

Visit us online at: https://www.aikenregional.com

Position Description:

This position manages the clinical documentation improvement program, identifying areas of focus for improvement opportunity through report analysis interpretation of process and operational reports, financial and compliance reports, and quality ratings reports.

Assists with various associated operational matters including appropriate scheduling and coverage of reviews, query development and auditing, educating physicians, monitoring the program, and refining the process as needed to clarify documentation in records. Coordinates follow-up on unanswered queries during the patient stay, as needed, to obtain prompt response to open queries.

Serves as a resource to physicians and administration regarding issues related to the appropriateness of inpatient DRG assignment. Works collaboratively with the CDI team to facilitate documentation within the medical record that supports patient’s severity of illness and risk of mortality utilizing strong communication skills with physician, physician extender, case manager, utilization reviewer, nurse or other healthcare professionals, utilizing appropriate querying tools to capture needed documentation.

Duties:

• Manages the operations of the Clinical Documentation Improvement (CDI) program. Manages departmental staff including day to day supervision, employee relations and staff development.
• Functions as the super-user and trainer for the CDI program and all application software used by staff to code/assign working MS-DRG, APR-DRG, SOI, and ROM.
• Serves as the lead educational resource for all internal customers on CDI program effectiveness and requirements related to compliant documentation for DRG revenue assurance, compliance and quality outcomes.
• Oversees CDIS audits to ensure compliant and effective queries.
• Will provide both the influence and guidance, as well as managing CDI team.
• Performs other duties as assigned/required.

Benefit Highlights

• Unlimited Employee Referral Bonus Program
• Competitive Compensation & Generous Paid Time Off
• Excellent Medical, Dental, Vision and Prescription Drug Plans
• Tuition/Certification Reimbursement after 6 months
• Culture of Excellence – Employee Recognition program
• Challenging and rewarding work environment
• Clinical Nursing Ladder opportunities
• SoFi student loan refinancing program
• 401(K) with company match and discounted stock plan
• Career development opportunities within UHS and its 300+ Subsidiaries!
• More information is available on our Benefits Guest Website: uhsguest.com

About Universal Health Services

One of the nation’s largest and most respected providers of hospital and healthcare services, Universal Health Services, Inc. (UHS) has built an impressive record of achievement and performance. Growing steadily since its inception into an esteemed Fortune500®corporation, annualrevenuesduring2025were $17.4billion.In 2026,UHS was again recognized as one of FortuneWorld’s Most Admired Companies™ and in 2025, waslisted in Forbes ranking of America’s Largest Public Companies.

Headquarteredin King of Prussia, PA, UHS has approximately101,500employees and continues to grow through its subsidiaries. Operating acute care hospitals, behavioral health facilities, outpatient facilities and ambulatory care access points, an insurance offering, a physician network and various related services locatedin 40U.S.states, Washington, D.C., Puerto Rico and the United Kingdom.For additional information visitwww.uhs.com

From Fortune, ©2025, 2026FortuneMedia IP Limited. All rights reserved. Used under license.

Qualifications

Requirements:

• Graduate of nursing program. BSN Preferred.
• Minimum of 5 years recent clinical experience in an acute care setting. Critical Care or Medical/Surgical preferred AND 3-5 years experience with inpatient coding and DRG guidelines. Requires the ability to work independently in a time-oriented environment is essential. Must have a working knowledge of Medicare reimbursement system and coding guidelines preferred. Excellent written and verbal communication skills required. Must have knowledge of age-specific needs and elements of disease processes and related procedures required. Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes. Computer literacy essential.
• Registered Nurse with current S.C. license AND RHIA, RHIT or CCS preferred.

EEO Statement

All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws.