Job Description

Job Title: Mgr-Clinical Documentation Imp
Job ID: 1900027E
Status: Full-Time
Regular/Temporary: Regular
Shift: Day Job
Facility: UPMC Pinnacle Hospitals
Department: Health Info-Admin-HBG
Location: 111 South Front Street, Harrisburg PA 17105


As the Manager of Clinical Documentation Improvement, you will direct the activities of the Clinical Documentation Improvement (CDI) department, facilitate modifications to clinical documentation to ensure accurate depiction of the level of clinical services and patient severity through extensive concurrent interaction with physicians, nursing staff and other caregivers, case management and health information coding staff.

  • Perform other related duties as required.
  • He/she is responsible for employing a staff that accurately and effectively provides the services necessary to ensure quality patient care within the PinnacleHealth System.
  • He/she also presents informational sessions on various aspects of health information to physicians, medical students, and other health care professionals in and out of the system
  • Ability to communicate effectively with physicians and other clinical professional staff
  • Perform assigned work safely, adhering to established departmental safety rules and practices; reports to supervisor, in a timely manner, any unsafe activities, conditions, hazards, or safety violations that may cause injury to oneself, other employees, patients and visitors.
  • Utilize general office equipment and computer systems/software applications necessary to perform functions.
  • Oversees compliance with government and agency regulations.
  • Coach and assist in developing CDI Specialists, and ensures continuing education is maintained
  • Builds and maintains productive inter/intra departmental and vendor work relationships to optimize operations.
  • Develops and manages direct reports; and oversees the development and management of indirect reports.
  • Develops and monitors strategic operating goals, objectives and budget; and reports operational performance, justification and/or corrective action.
  • Works with health, finance and physician groups to develop systems to facilitate complete documentation for data reporting purposes.
  • Serves as a resource to Physicians/Case Manager and other key professional staff in matter relating to published DRG information.
  • Monitors tracking response to CDI and trending completion of DRG worksheets via reports generated by Clinical Documentation Specialists (CDS).
  • Interacts with physician regarding documentation appropriate to diagnosis and support appropriate levels of severity of illness and risk of mortality.
  • In conjunction with CDI Specialists, serve as the liaison to key stakeholders in the program
  • Develop and maintain effective working relationships with key stakeholders in CDI program.
  • Ensures recommendation of possible refinement of principal diagnosis based on Clinical data on admission and concurrently during the hospital stay to facilitate appropriate DRG assignment.
  • Ensures follow up reviews of clinical documentation are conducted by CDS staff to evaluate whether issues discussed and clarified with the physician have been recorded in the patient's chart.
  • Ensures clinical documentation, including modifications, accurately reflect the level of service rendered and severity of illness (in compliance with government and other regulations) for all patients:? Oversees a system to identify admissions with specific diagnosis/DRG classifications or other categories of admissions.? Ensure chart review within 48-72 hours of admission to meet criteria.? Ensures periodic documentation review with cases that have a length of stay greater than 3 days.


Bachelor's Degree in healthcare field. Nursing or Health Information Management related field, required. Current license to practice as a Registered Professional Nurse in Pennsylvania or Register Health Information Administrator (RHIA).Minimum of seven (7) years of progressive experience in an acute care setting. Previous experience in chart review, required. Regulatory background and DRG reimbursement knowledge, preferred.Ability to communicate effectively with physicians and other clinical professional staff.

Licensure, Certifications, and Clearances:
  • Act 33 with renewal
  • Act 34 with renewal
  • Act 73 FBI Clearance with renewal

  • UPMC is an equal opportunity employer. Minority/Females/Veterans/Individuals with Disabilities

    Salary Range: $31.93 to $49.48 / hour

    Union Position: No

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