Manager Clinical Documentation

Clinical Documentation Improvement Manager

The manager of CDI is responsible for managing, coordinating and facilitating activities for the quality and completeness of clinical documentation. Manages CDI staff and concurrent review activity at the facility level, including performing record reviews on admissions and documents findings. Facilitates compliant modifications to clinical documentation to accurately reflect patient severity of illness, risk of mortality through extensive interaction with physicians, Case Management, other patient care givers and HIM / Coding staff. Serves a CDI resource. Facilitates accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes. Monitors and evaluates effectiveness of concurrent chart review and query outcomes at designated intervals. Reports CDI data to hospital departments and committees at designated intervals as assigned. Maintains accurate records to comply with departmental and regulatory agency guidelines. Understands and complies with policies and procedures related to confidentiality of medical records. Directs and assists departmental team members with assigned responsibilities as needed. Facilitate communication and teambuilding. Identifies opportunities for intradepartmental and interdepartmental operational improvements. Coordinates and collaborates for CDI policies / procedures / guidelines as well as process development, implementation and re-evaluation. Supports CDI Physician Advisors at the facility level, including CDI education efforts for the medical staff. Participation and management of special CDI projects as assigned. Plans, facilitates and participates in staff development, departmental activities and in-service opportunities. Demonstrates actions consistent with FMOLHS code of conduct.