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Role Description

The position has responsibility for the daily planning, work scheduling and coordination, and operational performance of the defined Clinical Documentation Integrity program. Delegates, supervises personnel, solves problems, makes decisions and develops systems and processes for successful integration and implementation. Participates in interviewing, hiring, scheduling, training and evaluation of staff. Ensures the quality, consistency and timeliness of the facility medical record documentation that complies with federal and state regulations. Seeks guidance from the Director and/or upper management for unusual or unanticipated circumstances that require deviation from policy/practice or allocation of funds to resolve. Collaboration with the CDI Educator and Outpatient CDI Manager as a part of the system CDI Leadership Team.

Qualifications

• Registered Nurse (RN) license.
• Bachelor of Science in Nursing (BSN)
• Three (3) years’ experience as Clinical Documentation Specialist
• Five years acute care experience
• CCDS or CDIP Certification

Preferred Qualifications

• Master’s Degree
• Five (5) years’ experience as Clinical Documentation Specialist

Duties and Responsibilities

• Manages, develops and coaches the system-wide CDS team, motivating and supporting others in overcoming barriers to understanding.
• Helps develop a collaborative team, and manages multiple priorities simultaneously.
• Provides ongoing feedback to CDS team, physicians, administration from reports.
• Assists with performing staff evaluations, promoting longevity of program, providing feedback and conflict resolution to CDS team.
• Works in conjunction with Coding Liaison, CDI Educator and CDI Director to provide in-services and continuing education to the CDI team, physicians and clinical departments, providing highly complex information to audiences with a varied level of understanding of severity of illness and risk of mortality in an effort to ensure optimal reimbursement.
• Serves as a subject matter expert and authoritative resource. Assumes personal responsibility for professional growth, development and continuing education to maintain a high level of proficiency.
• Serves as support for the Director providing backup as necessary. Participates in job interviewing, assessment and selection of new employees. Maintains positive morale maintenance with clinical documentation improvement and contributes to and promotes departmental performance improvement initiatives and employee engagement. Maintains confidentiality of employees', patients', and administrative and medical staff's information with no infractions and performs other duties as assigned.
• Uses critical thinking and sound judgment in decision making keeping reimbursement considerations in balance with regulatory compliance.

Physical Requirements

• Work environment: professional office environment with typical office requirements such as computers, phones, photocopiers, filing cabinets, etc.
• This is largely a sedentary role, which involves sitting most of the time, but may involve movements such as walking, standing, reaching, ascending / descending stairs and operating office equipment.
• Frequently required to speak, hear, communicate and exchange information.
• Able to see and read computer displays, read fine print, and/or normal type size print and distinguish letters, numbers and symbols.
• Occasionally lift and/or move up to 25 pounds.
• Ability to work in confined or open environments.
• Ability to work independently or in a team environment.

Skills & Abilities

• Demonstrated leadership experience.
• Expertise in CDI, coding, and clinical medicine to serve as a subject matter expert for CDI program.
• Knowledge of ICD-10-CM / PCS, quality initiatives and specificity of documentation changes.
• Proficiency with Microsoft Office Suite and virtual meeting platforms.
• Excellent oral and written communication skills.
• Experience working collaboratively with HIM/Coding departments in partnership to improve reimbursement accuracy.
• Proven record of managing successful CDI programs with proven metrics and value add to the organization (preferred).

Job Profile Summary

This role focuses on activities related to revenue cycle operations such as billing, collections, and payment processing. In addition, this role focuses on performing the following CDI related duties: Facilitates improvement in overall quality, completeness, and accuracy of medical record documentation, obtains appropriate clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, and coding staff to ensure that documentation reflects the level of service rendered to patients is complete and accurate, and serves as a resource to all team members on documentation guidelines, provides guidance and support as well as assisting in the education and training related to improving clinical documentation. A management role that supervises employees focusing on tactical, operational activities within a specified area, with the majority of time spent overseeing area of responsibility, planning, prioritizing and/or directing the responsibilities of employees. Goal achievement is typically accomplished through performance of direct and/or indirect reports. A role that manages experienced professionals who exercise latitude and independence in assignments. Responsibilities typically include: policy and strategy implementation for short-term results (1 year or less), problems faced are difficult to moderately complex, and influences others outside of own job area regarding policies, practices and procedures.

Pay Range

$122,301.82 - $155,933.24