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Manager, Coding & Clinical Documentation

Burlington, Massachusetts; Winchester, Massachusetts

Organization Facility: Lahey Hospital and Medical Center Category: Clinical Documentation Improvement (CDI) Job ID: JR82145 Date posted: 09/15/2025
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Job Type: Regular

Time Type: Full time

Work Shift: Day (United States of America)

FLSA Status: Exempt

When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives.

The Manager of Coding & Clinical Documentation oversees a highly trained Clinical Documentation Specialist (CDS) team, working collaboratively with providers and clinical partners to ensure an accurate, complete, and compliant medical record. The Manager leads regional CDI initiatives, ensuring consistency in documentation practices, compliance, and performance across all assigned facilities.

The Manager, Coding & Clinical Documentation coordinates the Clinical Documentation Integrity Program (CDI) at Beth Israel Lahey Health (BILH), including collaboration with Physician leaders, Coding, DRG Validators, Physician Advisors and Performance Improvement departments. The Manager directly oversees the Clinical Documentation Specialists (CDS) in planning and implementing improvements with processes, while keeping staff engaged to drive both the success of CDS individuals and overall department goals. Continuously monitors processes for opportunities for improvement, coordinated within an interdisciplinary team, and integrated the Revenue Cycle effort. 

The Manager demonstrates a commitment to and performs in accordance with the mission, established policies, procedures, and standards of the CDI and BILH. Acts as a role model to staff members, promoting excellence in documentation integrity and improvement as well as professional values and behaviors, including Community, Respect, Excellence, Accountability, Teamwork, and Empathy.

Job Description:

Essential Duties & Responsibilities including but not limited to:

· Accountable for meeting defined key CDI best practice program performance targets

· Institute improvement action plans and compliance monitoring.

· Assist the CDI Director in evaluating systems and processes in collaboration with Revenue Cycle

· Participate in process improvement initiatives, working with a variety of departments.

· Assist leadership in managing multiple vendor relationships, IT setup, reports, and data analysis.

· Compile data for monthly CDI program and/or provider performance reports.

· Partner with the Physician Advisors on solutions to provider engagement.

· Provide ongoing informational presentations for providers and clinical service lines.

· Develop and provide orientation, training, and competency development for staff on an ongoing basis.

· Implement 2nd level review for targeted opportunity, including but not limited to quality, compliance, and mortality review.

· Assign and review staff schedules and workflows, and work closely with administrative colleagues.

· Conduct CDI candidate interviews and hire new employees.

· Liaison for problem resolution with CDI electronic applications: 3M360, Epic, remote/home workstations

· Keep current on department-related activities by reviewing various organizational communications and literature that include staff meeting minutes, etc.

· Attend work-related educational programs as required.

· Maintain necessary continuing education requirements for licensing, certification, and enhancements.

· Maintain own education records.

Organizational Requirements:

· Maintain strict adherence to the BILH Confidentiality Policy.

· Incorporate BILH Guiding Principles, Mission Statement, and Goals into daily activities.

· Comply with all BILH Policies.

· Complies with behavioral expectations of the department and BILH.

· Maintain courteous and effective interactions with colleagues and patients.

· Demonstrate an understanding of the job description, performance expectations, and competency assessment.

· Demonstrate a commitment toward meeting and exceeding the needs of our customers and consistently adhere to Customer Service standards.

· Participate in departmental and/or interdepartmental quality improvement activities.

· Participate in and successfully complete Mandatory Education.

· Perform all other duties as needed or directed to meet the needs of the department.

Education: Bachelor’s Degree in Nursing (preferred), related master’s degree highly desirable.

Licensure, Certification & Registration: Active Massachusetts Registered Nurse; CCDS or CDIP certification current or obtained within year of the role; Membership in a CDI-related national organization, such as ACDIS or AHIMA

Experience:

· Minimum of 5 years of progressive CDS experience, including at the supervisory/managerial level and/or actively involved in program development.

· A minimum of three years of medical/surgical nursing care experience

Skills, Knowledge & Abilities:

· Motivate colleagues to attain program and organizational goals

· Ability to promote teamwork

· Flexibility and able to pivot priorities

· Achieve program goals and objectives

· Ability to function in a highly impactful, fast paced environment

· Excellent written and verbal communication

· Subject matter expert with a full understanding and working knowledge of DRG assignments and metrics

· High level understanding of and working knowledge of coding guidelines for compliance purposes

· Ability to prepare and present data

· Effective verbal communication, problem solving and conflict resolution skills. · Basic knowledge of Quality Improvement techniques.

· Demonstrated ability to organize and work independently

· Demonstrated ability to communicate effectively with medical and hospital staffs.

· Proven knowledge of CDI operations within the Revenue Cycle

· Extensive clinical knowledge and understanding of pathology/physiology with clinical experience in a hospital acute care setting

As a health care organization, we have a responsibility to do everything in our power to care for and protect our patients, our colleagues and our communities. Beth Israel Lahey Health requires that all staff be vaccinated against influenza (flu) as a condition of employment. Learn more about this requirement.

More than 35,000 people working together. Nurses, doctors, technicians, therapists, researchers, teachers and more, making a difference in patients' lives. Your skill and compassion can make us even stronger.

Equal Opportunity Employer/Veterans/Disabled

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Why join Beth Israel Lahey Health?

If you’re looking for a career where you can make a difference and explore your potential, Beth Israel Lahey Health is the place you belong. Our system includes a network of hospitals, physician practices, outpatient centers, and other healthcare facilities and we offer a broad range of careers in direct patient care, environmental services, registration, finance and many other fields. We are focused on providing compassionate and personalized healthcare with a strong reputation for clinical excellence and research and offer diverse opportunities for career growth and development. Conveniently, we have many locations in communities across Eastern Massachusetts and Southern New Hampshire.

At Beth Israel Lahey Health, we see you for all that you are – your experience and your dreams. Explore our open opportunities and find out why so many have already chosen to join our team.

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