Clinical Documentation Integrity Program Manager

Description

Using advanced knowledge of documentation/regulatory/payer requirements and in-depth clinical expertise, manages the Clinical Documentation Improvement (CDI) Program that promotes overall quality, completeness and accuracy of medical record documentation by the Medical Staff and other members of the interdisciplinary team.Core Competencies

• Interviews, hires and trains staff.; plans, assigns and directs, evaluates employee performance; provides corrective action to staff, addresses complaints and resolves problems.
• Oversees and assigns work so that productivity is maintained at acceptable levels and tasks are completed on a daily basis.
• Produces reports to document: productivity; user activity; query response rate; etc
• Participates in performance improvement activities (PI projects, task forces, etc) when warranted.
• Writes, revises policies and procedures.
• Participates/attends in committees, staff meetings, activities, mandatory inservices and inservices as assigned or required.
• Understands and applies educational techniques for adult learners.
• Demonstrates strong organizational skills and attention to detail.
• Works on many different projects during one time frame and coordinates work so deadlines are met.
• Assists the Director in the financial management functions of the department inclusive of budget development, implementation and control.
• Demonstrates excellent written and verbal communication abilities and creates mechanisms to facilitate effective organization-wide communication.
• Accepts responsibility for effective two-way communication using clear and well-organized oral and written techniques. Demonstrates self-awareness of non-verbal messages, keeping verbal and non-verbal messages consistent. Incorporates recognition of cultural impact on understanding and effectively uses interpreters and language translation devices.

Department Specific Competencies

• Assists in developing, implementing, and managing an effective and efficient CDI program. Works collaboratively with and educates physicians and other providers regarding clinical documentation integrity and the need for accurate and complete documentation in the health record.
• Participates in the ongoing evaluation of the structure, processes and outcomes of the data collection and benchmarking systems. Works with HIM management and the coding team in developing and maintaining current materials to prompt clinicians to accurately document (example: query forms). Actively manages the ongoing evaluation of the CDI program and provides creative, constructive, and realistic recommendations for change.
• Assesses patients' clinical conditions and risks compared to the physicians' documentation in accordance with regulatory and documentation standards using applicable coding conventions, rules and guidelines. Through data analysis, determines patient populations upon which to focus that will yield the greatest impact for improvement in outcomes.
• Utilizes computer software for documentation of reviews and clarifications. Manages the development of or utilizes computerized tracking methods to identify and prioritize records for review each day.
• Demonstrates an expert level of understanding of all regulatory/accrediting agencies' standards.
• Provides data for statistical reports and analysis.
• Plans educational/training programs to address organizational and employee development needs and provides ongoing evaluation of outcomes.
• Assists in developing an annual strategic educational plan based upon changes in regulatory standards and physicians' and other clinicians' level of compliance.
• Recognizes physicians and other clinicians who demonstrate compliance with documentation requirements.
• Works collaboratively with Medical Staff leaders in addressing issues of physicians who require further education to help them with documentation requirements.

Education
DegreeProgramN/AN/A
Additional InformationBachelor Degree or higher education in healthcare.
Experience
Number of Years ExperienceType of Experience3Clinical Documentation Improvement (CDI)
Additional InformationAlso requires one (1) year of management experience in a CDI Program. In addition to the CDIP or CCDS certification, also requires the addition of either a Registered Nurse (RN) licensed in the State of California, or Registered Health Information Administrator (RHIA) certification, or foreign trained medical doctor credential or higher.
License / Certification Requirements
Certified Documentation Improvement Practitioner (CDIP).Certified Clinical Documentation Specialist (CCDS)
Compensation Range:

$114,608.00 - 190,361.00