System Director - CDI
Apply NowCompany: Hudson Regional Hospital
Location: Secaucus, NJ 07094
Description:
Position Summary
Analyzes and clarifies documentation in patient records related to condition, severity of illness and treatment plan to provide optimum coding accuracy for proper billing.
Job Duties
Responsible for facilitating the improvement in the overall quality and completeness of provider-based clinical documentation in the medical record
Assist treating providers to ensure that documentation in the medical record accurately reflects the severity of illness of the patient as well as the level of services rendered
Extensively interacts with providers, nursing staff, other patient care givers, and Health Information Management (HIM) staff.
Ensures that appropriate reimbursement is received for the level of services rendered to patients and the clinical information utilized in profiling and reporting outcomes is complete and accurate
Participates and leads in ongoing education of staff. Develops educational material and tools relative to documentation improvement practices for individual practitioners and groups of providers presented as handouts, PowerPoint, etc.
Fosters a collaborative environment with the HIM department team
Ability to critically and effectively analyze documentation in the medical record
Ability to develop and maintain compliant query practices
Knowledge of how clinical documentation impacts quality initiatives
Coordinate and assist in establishing activities for the HRH system hospitals.
Other duties as assigned Performs other duties as assigned.
Qualifications and Skills
Strong analytical, communication and organizational skills.
Proficient in Microsoft Office.
Education, Experience and Certification/Licensure Requirements
Medical Doctor or Registered Nurse
Minimum 5 years' experience in CDI
Must be ACDIS certified with 6 months of employment
Analyzes and clarifies documentation in patient records related to condition, severity of illness and treatment plan to provide optimum coding accuracy for proper billing.
Job Duties
Responsible for facilitating the improvement in the overall quality and completeness of provider-based clinical documentation in the medical record
Assist treating providers to ensure that documentation in the medical record accurately reflects the severity of illness of the patient as well as the level of services rendered
Extensively interacts with providers, nursing staff, other patient care givers, and Health Information Management (HIM) staff.
Ensures that appropriate reimbursement is received for the level of services rendered to patients and the clinical information utilized in profiling and reporting outcomes is complete and accurate
Participates and leads in ongoing education of staff. Develops educational material and tools relative to documentation improvement practices for individual practitioners and groups of providers presented as handouts, PowerPoint, etc.
Fosters a collaborative environment with the HIM department team
Ability to critically and effectively analyze documentation in the medical record
Ability to develop and maintain compliant query practices
Knowledge of how clinical documentation impacts quality initiatives
Coordinate and assist in establishing activities for the HRH system hospitals.
Other duties as assigned Performs other duties as assigned.
Qualifications and Skills
Strong analytical, communication and organizational skills.
Proficient in Microsoft Office.
Education, Experience and Certification/Licensure Requirements
Medical Doctor or Registered Nurse
Minimum 5 years' experience in CDI
Must be ACDIS certified with 6 months of employment