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Job Details

Director CDI

Location
Baltimore, MD, United States

Posted on
Feb 24, 2022

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What You Will Do:
General Summary
Clinical Documentation Director is responsible for overseeing the accuracy, completeness and consistency of clinical documentation to support coding and reporting of high-quality healthcare data. The role is guided by the Association of Clinical Documentation Improvement Specialists (ACDIS) and American Health Information Management Association's (AHIMA) Ethical Standards for Clinical Documentation Improvement Professionals. The Clinical Documentation Director leads, directs, monitors, and is responsible for the successful operations of all aspects of Clinical Documentation for the University of Maryland Medical System (UMMS) that report under Health Information Management. The role oversees and provides leadership for clinical documentation improvement, and optimal accurate assignment of ICD-10 diagnostic and procedural coding. Organizes and implements shared services for HIM functions with affiliated hospitals as needed and prescribed. This position will manage activities of the Clinical Documentation Improvement Program. Clinical Documentation Improvement Director will monitor the performance, collection and analysis of data to report on the effectiveness of process improvement to the organization and the system. Clinical Documentation Improvement Director will participate in the planning, development, implementation, and ongoing success of the Clinical Documentation Management Program.
II.
Principal Responsibilities and Tasks
The following statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all job duties performed by personnel so classified.
Provide leadership and on-going focus, advising and evaluating the work of Clinical Documentation Improvement Managers in accordance with departmental and System-wide policies, procedures and standards. Assist Clinical Documentation Improvement Managers with staffing schedules to ensure adequate coverage and optimize productivity across the health system. Oversee coverage and deploy staffing accordingly.
Implement, monitor, and govern a standardized approach to clinical documentation improvement across the health system. Develop and monitor strategic operating goals. Work collaboratively with providers, quality and coding to ensure the health record accurately captures the care provided. Participates in budget development and recommends budgets for areas of oversight. Tracks spending to budget for areas of oversight. Ensure Clinical Documentation Specialist Program activities are in regulatory compliance (JC, CMS). Represent Clinical Documentation Program on Case-Mix, MHAC and other related organizational committees.
Track clinical, functional, operational, quality and financial data related to Clinical Documentation Improvement. Collect and analyze data on program efforts and outcomes; identify patterns, trend variances, and opportunities to improve documentation review and process.
Report and track Clinical Documentation Specialist outcome data including ROI, CMI shift, ROM/SOI shift, PQI, MHAC, Mortality Score. Implement processes to continually improve performance, and optimize reimbursement. Update Departmental and Organizational procedures to reflect changes in coding guidelines and clinical parameters. Monitors any ongoing educational needs based on regulatory changes and/or areas identified by quality audits for improvement.Leads and directs processes that provide relevant data reports, and education to support a continuous quality documentation program, target activities to specific quality metrics, APR-DRGs, & Case-Mix based on financial and clinical data analysis. Assist in the development and reporting of performance measures to the medical staff and/or healthcare teams; prepare physician specific-data reports. Facilitate change process required to capture needed documentation such as query template/forms design. Develop ongoing physician/provider education strategies in collaboration with other Revenue Cycle, Coding, and Quality Departments to promote complete and accurate clinical documentation and correct negative trends. Evaluate and analyze statistical data including the ability to maintain databases, spreadsheets and related software and produce analytical reporting; weekly and monthly reports to monitor benchmark goals, key performance indicators, and identifying opportunities for improvement; provides feedback, develops and implements action plans when appropriate.
Hire, orient, train conduct performance evaluations, handle corrective actions and provide an open and goal oriented work environment with established clear and concise work procedures and productivity standards. Reviews recommendations of and provides guidance and counseling to staff regarding employee relations matters.
Complies with AHIMA and ACDIS standards of ethical coding and coding compliance guidelines.
Demonstrates support and compliance with University of Maryland Medical System mission, vision, values statement, goals and objectives and policies. Performs other duties or projects such as assigned.
III. Education and Experience
Bachelor's degree in Nursing or related healthcare field required. Master's degree in Health Care or related field preferred.
7 years progressive experience in an acute care setting.
7 years' experience as a Clinical Documentation Specialist. Advanced clinical expertise and extensive knowledge of complex disease processes with broad based clinical experience in an inpatient setting.
7 years
supervisory/management experience required in the coding and/or clinical documentation field, supervising professional staff.
Previous experience in quality metrics chart review.
One of the following: Registered Nurse (RN) Certified Coding Specialist (CCS), Certified Inpatient Coder (CIC), Certified Clinical Documentation Specialist (CCDS), Certified Documentation Improvement Practitioner (CDIP) Physician (MD), Physician Assistant (PA) , Certified Registered Nurse Practitioner (CRNP), Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA).
Managing multi-facility department's Regulatory background and APR-DRG reimbursement knowledge. Strong medical surgical background is preferred.
Experience with utilization management, coding, billing, auditing and various healthcare payers is preferred.
Experience in project management involving interdisciplinary teams is preferred.
What You Need to Be Successful:
IV.
Knowledge, Skills and Abilities
Strong analytical and organizational skills; filing systems; ability to prioritize workloads; meet deadlines and work effectively under pressure; excellent customer service skills; general office procedures; ability to problem solve and work with minimal supervision; familiar with basic medical terminology; computer experience; typing ability.
We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.

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