Clinical Documentation Improvement Manager RN

Baptist Health is the largest healthcare system serving central Alabama, providing comprehensive hospital-based and outpatient services to nearly 60 percent of the residents in Montgomery, Autauga and Elmore counties. To learn more about Baptist Health, visit us at https://www.baptistfirst.org.
They manage the clinical documentation improvement and integrity program by providing day to day intense oversight of the CDS program. This position will be responsible for increasing CDS program awareness with the goal of enhancing the appropriateness and comprehensiveness of documentation within the medical record to ensure patient safety and quality of care initiatives. The goal of the CDS team lead is to ensure that physician and allied health documentation accurately represents the condition and co-morbidities for patient (s) of the hospital. They will work in collaboration with clinicians, coding professionals, physicians, physician's assistants, and residents to ensure accurate and timely clinical documentation in the medical record that supports the coding process in attaining appropriate DRGs based on sound clinical entries in the medical record. They will support ongoing communication and education on documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies to physicians and entire hospital staff. In addition, the CDS team lead will assist in the maintenance of the CDS dashboard and report outcomes at the monthly CDS Committee Meeting. The team lead will mentor CDS staff as the program continues to grow based on identified needs.Description

• Nursing Degree required with 3 years experience as a CDS specialist.
• Active RN licensure required.
• Certified Documentation Specialist. (CCDS) required.
• Familiarity with MS-DRGs and the Inpatient Prospective Payment System (IPPS), including new CMS guideline of key elements including clinical documentation of what constitutes an inpatient admission (see 2014 IPPS proposed rule)
• Strong clinical knowledge and demonstrated commitment to maintaining relevancy in clinical field.
• Familiarity with ICD CM official coding guidelines.
• General knowledge of what constitutes a complete and accurate record-i.e. complete and thorough clinical documentation beginning with the presentation of patient to a inpatient status.
• Review medical record documentation for the reason for admission that clearly establishes and meets medical necessity criteria; need for continued stay in the hospital including response to treatments, interventions, and outcomes; complete and accurate discharge summary.
• Practical knowledge and understanding of official documentation requirements in support of principal and secondary diagnoses.
• Effective ability and willingness to communicate benefits of complete and accurate documentation to physicians.
• Commitment to continuously increasing knowledge in and familiarity in constantly changing updates in the business of medicine.