Clinical documentation specialist [h1.location_city]

Clinical Documentation Integrity Manager

Work Remote Position

At the direction of the Regional Manager, Clinical Documentation Integrity (CDI), this position supervises daily operations of the CDI program for the Health Ministries (HMs) within their region. Provides direct oversight of the Clinical Documentation Specialist and Clinical Documentation Integrity Coordinator.

Working with the Regional Manager, Clinical Documentation Integrity, is directly responsible for the daily assessments of current Clinical Documentation Specialist staffing levels and processes. Ensures that defined goals are accomplished utilizing timely and compliant processes within the region and in concert with the Trinity Health System Office CDI program standards, policies, procedures, and workflows.

Assists with policy and education development on the use of guidelines and proper documentation requirements as it relates to reimbursement and other clinical data quality management for colleague training. Provides quality and productivity monitoring; coordinates and participates in performance improvement initiatives. Provides training and education to clinical documentation specialists (CDS) to enhance clinical and coding skill sets and optimal utilization of the 3M CDI software. Responsible for scheduling and work assignments for colleagues.

Works closely with Clinicians, Coding, Quality, and Denials teams to facilitate documentation within the medical record and supports the patient's severity of illness, risk of mortality, clinical validity, and proper DRG assignment.

Knows, understands, incorporates, and demonstrates the mission, vision, and values of the Ministry in leadership behaviors, practices, and decisions.

Directly supervises the daily operations for the CDI team who work onsite and remotely.

Communicates effectively with staff to ensure defined regional and / or system goals are met.

Maintains current knowledge of the MS-DRG system, CCs / MCCs, impact on quality, risk of mortality, severity of illness, and CMI as well as ICD-10 coding systems and the guidelines related to Clinical Documentation Integrity.

Facilitates appropriate clinical documentation to ensure that the severity of illness, risk of mortality, and level of services provided are accurately reflected in the health record.

Assists in overall quality, timeliness, and completeness of the quality health record to ensure appropriate data, provider communication, and quality outcomes. Serves as a resource for appropriate clinical documentation.

Responsible for scheduling and staffing assignments for the Clinical Documentation Specialist and Clinical Documentation Integrity Coordinator positions, facilitating management of personal time off and schedule change requests, assuring adequate staffing is in place. Monitors time and attendance system along with maintaining attendance records. Coordinates the work of external resources when used.

Along with the Clinical Documentation Integrity Coordinator, facilitates training of all new CDS hires.

Assists the Regional Manager, Clinical Documentation Integrity, in the recruitment, retention, and supervision of CDI staff. Participates in the development of staff, including fostering teamwork, providing performance feedback, mentoring CDS, and scheduling education. Collaborates with the Regional Manager, Clinical Documentation Integrity, on competency assessments, performance evaluations, counseling, and / or conflict resolution.

Communicates with and educates physicians and all other members of the healthcare team regarding clinical documentation and monitors provider participation. Identifies learning opportunities for healthcare providers. Ensures that direct reports communicate, educate, and engage with physicians and other members of the healthcare team regarding clinical documentation.

Collaborates with coding staff to assure documentation of discharge diagnoses and co-morbidities are a complete reflection of the patient's clinical status and care. Ensures appropriate and accurate DRG assignment. Resolves all discrepancies in a courteous manner.

Demonstrates a thorough understanding of the MS-DRG system, CCs / MCCs, impact on quality and CMI as well as ICD-10 coding systems and the guidelines related to Clinical Documentation Improvement. Serves as a resource for the CDS team for any of the above.

Provides input for policy and procedure maintenance and development. Assists with the collection, aggregation, and analysis of data. Collaborates in development and monitoring of performance to measure process outcomes, quality, and productivity, and to ensure continual process improvements.

Ensures that direct reports remain current in coding guidelines and other regulatory directives that impact CDI performance. Ensures all compliance and regulatory standards are met.

Ensures that direct reports perform clinical validation as part of the review process and remain current on CDI strategies.

Maintains superuser level skill set in the use of 3M / 360 and leverages technology and system reporting to improve CDI team efficiency and effectiveness. Monitors the CDI Dashboard and reporting to identify opportunities for improvement and areas of focus.

May perform CDI reviews to support program during high volume, short staffing periods.

Maintains a working knowledge of applicable Federal, State, and local laws and regulations, Trinity Health Corporate Integrity Program, Code of Ethics, as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical, and professional behavior.

Bachelor's Degree in Health Information Management, Healthcare related field or Nursing or equivalent in experience.

Must possess one of the below :

• Current Registered Nurse (RN) License
• Registered Health Information Administrator (RHIA)
• Registered Health Information Technician (RHIT)
• Certified Coding Specialists (CCS)
• Licensure as a physician assistant (PA) or Nurse Practitioner / Advanced Practice Nurse (NP / APN) or completion of medical school
• Certified Clinical Documentation Specialists (CCDS) or Certified Documentation Improvement Professional (CDIP) preferred

Minimum of five (5) years of current hospital clinical documentation integrity program experience is required. Two (2) or more years of current experience supervising hospital clinical documentation integrity program is required.

Must have thorough knowledge of CMS regulations, coding guidelines, and DRG reimbursement.

Demonstrated knowledge of state and federal Hospital Acquired Conditions (HAC) and other applicable quality indicator codes (i.e. PSI, PPI, etc.).

Demonstrated, current expertise with 3M CDI Software. Working knowledge of Epic EMR preferred.

Must possess strong analytical and critical thinking skills in order to detect and resolve problems related to clinical documentation integrity.

Demonstrated ability to effectively supervise diverse and geographically dispersed teams both onsite and remote.

Excellent interpersonal skills with ability to build collaborative working relationships with clinical staff, finance, and compliance.

Must possess strong written and verbal communication skills to effectively supervise clinical documentation integrity activities and communicate with a wide-ranging audience.

Intermediate computer skills required, including working knowledge of and experience using MS Word, Excel, Outlook, and PowerPoint. Must be able to spend majority of work time utilizing a computer, monitor, and keyboard.

Maintains professional attitude and ability to relate well with leadership, physicians, other care providers, colleagues, and patients and others within the scope of the position.

Strong understanding of the Catholic health ministry in an evolving health care delivery system and changing reimbursement market.

Personal presence that is characterized by a sense of honesty, integrity, and caring as well as the ability to inspire and to motivate others to promote the philosophy, mission, vision, goals, and values of the Ministry.

Our Commitment

Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.