Manages the daily operations of the Clinical Documentation Improvement department and employees. Develops and implements work policy and procedures, to produce desired outcomes, while effectively and efficiently utilizing departmental and hospital resources to assure high quality documentation and accurate, complete, and timely reviews of inpatient medical records. . Responsible for developing and maintaining a thorough knowledge of the organization's policy and procedures, TJC requirements, ACOS requirements, HCFA and state regulations, correct coding initiatives, and principles of Clinical Documentation Improvement. Continually identifies quality improvement opportunities within the clinical and operations segments.
Collaborates with physician, physician extender, nurse, case manager/utilization reviewer and coding staff to identify principal diagnosis options, secondary diagnoses and procedures, to assign concurrent DRGs on identified populations. Identify and work with case management on potential cases where diagnosis may not meet inpatient status.
Identifies and develop corrective processes to clarify documentation in records, and utilizes strong communication skills with physician, physician extender, case manager, utilization reviewer, nurse or other healthcare professionals, utilizing appropriate tools to capture needed documentation. Develop and implement a CDI query quality review process and training to the CDI team regarding outcomes and accuracy of the queries. Works collaboratively with the care teams to facilitate documentation within the medical record that supports patient’s severity of illness, risk of mortality and Core Measures. Utilizes monitoring tools within CDI tool to track the progress of the DRG assurance program, as well as, monitoring reports and data.
Monitor and report standard program metrics. Prepare and present to varying audiences on program, outcomes and areas of opportunity through in-depth analysis. Serves as a resource to physicians and administration regarding issues related to the appropriateness of DRG assignment. Maintains complete confidentiality of patient information, in addition to hospital and individual physician practice pattern data.
Perform other duties as assigned.
• RN or similar clinical experience
• 5 years of experience in a large hospital system.
• CDMP/Documentation Integrity Clinical outcomes
• Strong knowledge of reimbursement and coding structures
• Facilitation and project management skills.
• Strong computer and data analysis skills; comfortable with the use of Microsoft Word, Excel, and
• PowerPoint including the use of pivot tables and statistical analysis tools.
• ACDIS Certification
• BSN or degree in health care administration
• Masters level education suggested
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