Major Responsibilities:Provides management oversight of the daily operations of the clinical documentation program at assigned sites. Responsible for interviewing, hiring, orientation, and ongoing competency assessment of CDI staff in collaboration with the Director of CDI operations. Conducts performance evaluations, salary reviews, and corrective action for the CDI staff. Approves and monitors staff schedules, paid time off, and time cards to ensure continuity of services. Monitors proficiency of each sites’ CDI staff and includes action plans to improve deficiencies. Responsible for team building and conflict resolution.Facilitates performance improvement activities for the clinical documentation management program. Identifies and discusses overall and individual physician documentation trends with Director of CDI Operations and site Medical Staff Leadership as appropriate with a documented improvement plan with strategies and educational needs identified.Creates and runs reports from the Clinical documentation management program in order to effectively evaluate both individual associate and overall site program performance. Analyzes data and information to discern root causes of performance gaps using key data and reports. Regularly reviews individual site successes and improvement opportunities with the Director of CDI Operations and other key stakeholders.Serves as an internal consultant on clinical documentation opportunities. Acts as an expert resource for CDI program, including support for mismatch resolution and regulatory on of challenging cases, intervening with physicians when necessary, dissemination and interpretation of key regulatory requirements and changes, etc.,Consults, communicates and organizes key ongoing education, serves as co-leader of site clinical documentation steering committees and other site meetings as appropriate.Responsible for personal professional growth. Participates in professional organizations, maintains licensures and certification as required, maintains effective working relations with both internal and external customers, maintains required competencies and assumes responsibility for personal development and maintenance of ongoing knowledge of current clinical documentation standards and regulatory requirements through participation at workshops, conferences and or in services and maintaining records of participation.Collaborates with Directors CDI Operations, team members related to team members and physician engagement strategies. Ensures enterprise CDI program operates under compliant CMS, AHIMA, and ACDIS practice standards and codes of ethics. Collaborates with compliance to ensure the enterprise CDI program meets all state and federal guidelines.Performs human resources responsibilities for staff which include interviewing and selection of new employees, promotions, staff development, performance evaluations, compensation changes, resolution of employee concerns, corrective actions, terminations, and overall employee morale.Develops and recommends operating and capital budgets and controls expenditures within approved budget objectives.Responsible for understanding and adhering to the organization's Code of Ethical Conduct and for ensuring that personal actions, and the actions of employees supervised, comply with the policies, regulations and laws applicable to the organization's business.
Licensure, Registration, and/or Certification Required:Registered Nurse license issued by the state in which the team member practices, or Medicine and Surgery, MD-DO license issued by the state in which the team member practices, and Certified Clinical Documentation Specialist (CCDS) designation issued by the Association of Clinical Documentation Improvement Specialists (ACDIS).
Education Required:Bachelor's Degree (or equivalent knowledge) in Nursing, or Doctorate Degree in Medicine.
Experience Required:Typically requires 5 years of experience in a clinical environment. Includes 1 year of supervisory experience in a clinical environment.
Knowledge, Skills & Abilities Required:Ability to prioritize and organize work. Able to respond to multiple requests simultaneously.Ability to travel and work across multiple sites as assigned.Effective communication skills.Utilization of critical thinking in timely decision making.Knowledge of MS office products.Demonstrates leadership skills.Knowledge of Medicare Part A and B guidelines and how they impact DRG assignment.Knowledge of Regulatory environment.Ability to prioritize independently.
Physical Requirements and Working Conditions:Generally exposed to normal office environment.Position requires travel so there will be exposure to weather and road conditions.Potential for exposure to mechanical, electrical and chemical hazards and therefore be able to wear protective clothing as necessary.Must have functional speech, vision, smell, touch and hearing.Operates all equipment necessary to perform the job.
This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.