Manager, Medical Documentation

 

Role Overview

The Manager, Medical Documentation, oversees the end-to-end management of medical documentation, prescriptions, Standard Written Orders (SWOs), and Certificates of Medical Necessity (CMNs). This role ensures documentation is accurate, complete, and compliant with regulatory standards, payer requirements, and organizational policies to support timely patient care and reimbursement.

Reports To: Senior Director, Revenue Cycle

Responsibilities and Job Duties
Team Leadership & Performance Management
• Lead and manage the daily activities of documentation specialists to ensure accuracy, timeliness, and quality standards are consistently met.
• Assign work, delegate responsibilities, and monitor workload distribution and completion.
• Coordinate staffing coverage to maintain daily productivity and service levels.
• Conduct regular one-on-one meetings to review performance, set goals, and provide coaching and feedback.
• Establish department goals, monitor productivity and quality metrics, and deliver ongoing performance feedback.
• Lead daily team huddles to communicate priorities, updates, and reinforce collaboration.
• Foster strong collaboration with clinical, billing, sales, and intake teams to resolve documentation barriers.
• Develop and execute strategies to reduce held revenue related to missing or incomplete documentation.
• Utilize staff, time, and resources effectively to meet departmental and organizational objectives.
• Participate in the rotating qualification team schedule, including after-hours on-call coverage as required.
Documentation Oversight
• Oversee the collection, review, and validation of medical documentation to ensure accuracy and completeness.
• Ensure all documentation, SWOs, and CMNs meet CMS regulations, payer guidelines, and HIPAA requirements.
• Conduct routine audits to identify documentation gaps, errors, and compliance risks.
• Maintain organized, audit-ready documentation records for internal and external reviews.
• Monitor turnaround times to prevent delays in patient care, billing, or reimbursement.

Process Improvement & Compliance

• Develop, implement, and update policies and procedures to remain aligned with regulatory and payer requirements.
• Identify workflow inefficiencies and implement process improvements to enhance accuracy and turnaround time.
• Leverage technology and system tools to improve documentation quality and operational efficiency.
• Track and report key performance indicators (KPIs), providing actionable insights and recommendations to leadership.
• Maintain and update departmental Quick Reference Guides and documentation resources.
Training & Development
• Train and educate staff on documentation standards, system workflows, and compliance best practices.
• Partner with the Talent Development Manager to plan and deliver onboarding and ongoing training initiatives.
• Oversee EMR-related updates impacting CMNs, including template configuration and reporting support.

Education:

• Bachelor’s degree preferred, high school diploma or G.E.D equivalent required

Experience/Knowledge/Skills/Physical Requirements:

• 3-5 years of experience in medical documentation or DME/HME revenue cycle operations.
• Prior leadership or supervisory experience required.
• Strong working knowledge of Medicare, Medicaid and commercial payer documentation requirements.
• Demonstrated analytical, communication, and coaching skills.