Director, Clinical Document Integrity | Clinical Documentation Improvement (CDI)

Overview:

The Director of Clinical Documentation Integrity (CDI) provides strategic, operational, and clinical leadership for an enterprise-wide CDI program across the University of Florida Health System. This role advances documentation excellence to ensure accurate reflection of patient acuity, severity of illness, risk of mortality, quality outcomes, and appropriate reimbursement. The System Director will design and execute a forward-looking CDI strategy aligned with value-based care, regulatory compliance, and the organization's academic mission.

Responsibilities:

• Lead the enterprise CDI strategy across all UF Health entities, partnering with Directors and Managers to plan, organize, implement, and evaluate inpatient, outpatient, and professional CDI programs that ensure consistency and scalability system wide.
• Establish standardized workflows, policies, and procedures across facilities and service lines to support high-quality concurrent and retrospective reviews.
• Oversee CDI staffing models and productivity/quality standards, including management of key metrics such as case mix index (CMI), length of stay (LOS), observed vs. expected mortality (O/E), evaluation and management (E/M) levels, and Hierarchical Condition Category risk adjustment factors (HCC-RAF), in collaboration with Utilization Management and physician leadership.
• Develop and lead physician engagement strategies to elevate documentation practices across clinical departments and academic faculty.
• Collaborate with physician advisors and clinical leaders to promote adoption of CDI initiatives and technology solutions.
• Design and deliver targeted education on documentation best practices, severity of illness and risk of mortality capture, and regulatory and compliance requirements.
• Establish and co-lead a Clinical Documentation and Coding Center of Excellence (CoE) in partnership with Coding leadership to standardize training, quality assurance, and best practices across both functions.
• Own the enterprise CDI quality assurance strategy, including audit design, inter-rater reliability programs, and continuous feedback mechanisms to drive documentation accuracy and consistency.
• Serves as a trusted advisor to clinical departments and academic faculty.

Qualifications:

Education: 

• Graduate of an accredited school of nursing with current RN licensure in the State of Florida

 

Experience:

• Minimum 7 years of experience as a CDI specialist.
• Minimum 4 years managerial or director experience in a large academic medical center.

 

License/Certifications (if applicable):

• Registered Nurse (RN) required.
• Certified Clinical Documentation Specialist (CCDS) certification preferred and required within one year of employment. 
• Exceptional critical thinking skills with the ability to identify undocumented clinical findings supported by medical record evidence and clinical indicators.
• Demonstrated ability to lead, motivate, and develop teams to achieve program and organizational goals.
• In-depth knowledge of DRG assignment methodologies and CDI metrics in the inpatient setting.
• Strong understanding of E/M level selection and risk adjustment methodologies (including HCCs) across inpatient, emergency department, and outpatient settings.
• Sound judgment in balancing reimbursement optimization with regulatory compliance.
• Excellent verbal and written communication skills with the ability to influence at all levels of the organization. 
• Experience with Epic, Iodine, and MD Audit preferred.