Director, Clinical Documentation Improvement
EASTAR Health System - Muskogee, OK

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The Clinical Documentation Improvement (CDI) Director is responsible for development of CDI program and will play a key role in ensuring the success of a major revenue cycle initiative, the position provides strategic planning and concentrated daily oversight of the Clinical Documentation Improvement program.
The CDI Director will work with hospital leadership, physicians, and other providers to improve the overall quality and completeness of clinical documentation in the medical record to ensure that an accurate reflection of the severity of illness and the quality of care is captured. The CDI Director works to educate providers on the value of more granular documentation to their quality scores, risk of mortality data, length of stay and continuity of care for the patient. This role serves as a translator between Finance and the Clinical Staff, and plays a vital role in improving accurate quality reporting for both providers and the facility. The Director, in conjunction with the HIM Leadership, will lead the effort to ensure that accurate DRG-based reimbursement for the hospital is achieved and claims denials are reduced, by ensuring documentation integrity. The role will interface with compliance, management and key physician leaders at the hospital as it prepares strategically for a competitive future in today\'s healthcare market.
- Ensures that provider documentation provides an accurate reflection of the patient’s severity of illness and that appropriate diagnoses are rendered with adequate specificity, by concurrently reviewing all relevant inpatient admissions, performing a gap-analysis to determine where short-falls exist in the progress notes, and verbally and/or in written communications to the providers address and identify options for appropriate specificity that may be lacking.
- Provides education to operational leaders, staff and physicians on the importance of the Clinical Documentation Improvement Program (CDIP), and works cooperatively with them to ensure that improved documentation is seen as a part of the strategic mission.
- Facilitates modifications to clinical documentation through extensive concurrent interactions with physicians, nursing staff and coding teams to ensure that appropriate reimbursement and severity of illness (SOI) is captured.
- Responsible for attaining Key Performance Metrics and Financial goals set annually by the facility in conjunction with the system.
- Assists the assigned coder with concurrently reviewing the medical records of inpatients and subsequently discusses documentation opportunities with the various physician teams.
- Acts as consultant to coders when additional information or documentation is needed to assign the correct principal diagnosis, secondary diagnoses and appropriate DRG.
-Manages the department budget, responsible for hiring and supervision of (future) staff, Participates in hospital-wide committees related to key revenue-cycle goals and initiatives where documentation may drive success.
Graduate from an accredited school of nursing; RN is required. BSN or BA/BS degree is required. A minimum of 5 years of Med/Surg nursing experience is required. A strong knowledge of pathophysiology and treatment management across multiple practice areas is required. Critical care experience, ICU or ER, is preferred. Knowledge of ICD-9, ICD 10, coding or billing is desirable. Must have current license to practice as Registered Nurse.
This is a full time exempt position.

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