Clinical Documentation Improvement Manager - Richmond University Medical Center

Under direction of the Administrative Director, the incumbent manager, plans, directs, and coordinates the operations of the Clinical Document Improvement (CDI) department; assures compliance to conduct complex and difficult research and analytical studies involving the operations and programs of the department served; makes recommendations for the development, implementation and improvement of departmental operations, services, and programs; performs other related duties as required.

The Clinical Document Improvement Manager is the supervisory level classification in the Clinical Document Improvement series, performing the full range of supervisory duties. Incumbents will coordinate and organize the CDI for inpatient services, facilitate physician documentation, denials, and coding, and collaborate with physicians, directors, providers, and other healthcare team members to make improvements that result in accurate, comprehensive documentation that reflects completely, the clinical treatment, decision, and diagnoses for the patient. Incumbents may participate in the employee selection process, training, coaching and mentoring of employees.

EXAMPLES OF ESSENTIAL DUTIES

• Plan, assign and direct the work of a unit of Clinical Documentation Improvement Specialists.

• Develop and deliver training and education to clinical, CDI and coding professionals regarding CDI practices, coding and documentation requirements.

• Actively communicate with providers to clarify information and communicate documentation requirements for appropriate diagnoses based on severity of illness and risk of mortality.

• Develop and recommend policies and procedures; develop written procedures to clarify or describe standard practices; coordinate the publication and dissemination of procedures.

• Ensure admission reviews of patients' records are completed within 24-hours of notification of admission to evaluate and analyze documentation in order to assign the principal diagnosis, pertinent secondary diagnoses and procedures for accurate and optimal MS-DRG/APR-DRG assignment.

• Initiate and perform concurrent documentation reviews of selected inpatient records to clarify conditions/diagnoses and procedures where inadequate or conflicting documentation exists, and conduct follow-up reviews as necessary.

• Develop and implement methods of improving the clarity, accuracy and completeness of clinical documentation; monitor and evaluate coding outcomes and provide periodic status to medical center departments and committees.

• Communicate with and serve as a resource for physicians, nurses, and other healthcare providers to facilitate complete and accurate documentation of the patient record; query physicians regarding missing, unclear or conflicting medical record documentation and obtain additional documentation; keep physician leaders informed of pertinent data, documentation trends and opportunities for learning and improvement related to documentation integrity.

• Collect data for performance improvement and report findings and outcomes; participate in the analysis and trending of statistical data for specified patient populations to identify opportunities for improvement.

• Participate in revenue cycle meetings, providing data relative to reimbursement concerns; educate physicians and healthcare providers regarding documentation matters related to coding, billing and reimbursements.

• Select, train, assign, discipline, and evaluate the work of an assigned staff; write and discuss work performance evaluations.

Minimum Qualifications:

License:

Must possess and maintain Registered Nurse licensure

Experience:

Three (3) years of experience as a Registered Nurse in an acute care hospital, which included one (1) year of case management experience and one (1) year of experience as a lead or charge nurse. Experience may be concurrent.

Certification: Must possess a CCS and CCDS

Desired Qualifications

The ideal candidate will have at least five (5) years of supervisory experience over professional nursing staff in an acute care facility.

Salary Range: $90,000-$110,000

Employment Non-Discrimination: Richmond University Medical Center is committed to equality of opportunity in all aspects of employment and provides full and equal employment opportunities to all employees and potential employees without regard to race, color, national origin, religion, gender identity, sex, sexual orientation, pregnancy, childbirth and related medical conditions and needs including lactation accommodations, physical or mental disability, age, immigration or citizenship status, veteran or active military status, genetic information, or any other legally protected status.

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