临床文档完整性主管
Supervisor, Clinical Documentation Integrity
职位类型：
全职
班次：
描述：
职位目的
在区域经理，临床文档完整（CDI）的指导下，该职位负责监督其区域内卫生部（HMs）的CDI项目的日常运营。直接监督临床文档专员和临床文档完整协调员。
与区域经理，临床文档完整合作，直接负责对当前临床文档专员人员配置和流程进行日常评估。确保在区域内及时且符合规定的流程，以及与三一健康系统办公室CDI项目标准、政策、程序和工作流程一致，完成既定目标。
协助制定政策和教育内容，关于指南的使用和与报销及其他临床数据质量管理相关的正确文档要求，用于同事培训。提供质量和生产率监控；协调并参与绩效改进计划。为临床文档专员（CDS）提供培训和教育，以提高临床和编码技能，并优化使用3M CDI软件。负责安排同事的工作时间和任务分配。
与临床医生、编码、质量及拒付团队密切合作，促进医疗记录中的文档，并支持患者的病情严重程度、死亡风险、临床有效性及正确的DRG分配。
核心职责
了解、理解、融入并展示教区的使命、愿景和价值观，在领导行为、实践和决策中体现。
直接监督在场和远程工作的CDI团队的日常运营。
与员工有效沟通，确保实现定义的地区和/或系统目标。
保持对MS-DRG系统、CCs/MCCs、对质量、死亡风险、病情严重程度和CMI的影响，以及ICD-10编码系统和与临床文档完整相关的指南的最新了解。
促进适当的临床文档，以确保病情严重程度、死亡风险和服务水平在健康记录中准确反映。
协助整体质量、及时性和完整性，确保健康记录中适当的数据、医师沟通和质量结果。担任
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Employment Type:
Full timeShift:
Description:
POSITION PURPOSE
At the direction of the Regional Manager, Clinical Documentation Integrity (CDI), this position supervises daily operations of the CDI program for the Health Ministries (HMs) within their region. Provides direct oversight of the Clinical Documentation Specialist and Clinical Documentation Integrity Coordinator.
Working with the Regional Manager, Clinical Documentation Integrity, is directly responsible for the daily assessments of current Clinical Documentation Specialist staffing levels and processes. Ensures that defined goals are accomplished utilizing timely and compliant processes within the region and in concert with the Trinity Health System Office CDI program standards, policies, procedures and workflows.
Assists with policy and education development on the use of guidelines and proper
documentation requirements as it relates to reimbursement and other clinical data quality management for colleague training. Provides quality and productivity monitoring; coordinates and participates in performance improvement initiatives. Provides training and education to clinical documentation specialists (CDS) to enhance clinical and coding skill sets and optimal utilization of the 3M CDI software. Responsible for scheduling and work assignments for colleagues.
Works closely with Clinicians, Coding, Quality and Denials teams to facilitate documentation within the medical record and supports the patient’s severity of illness, risk of mortality, clinical validity and proper DRG assignment.
ESSENTIAL FUNCTIONS
Knows, understands, incorporates, and demonstrates the mission, vision, and values of the Ministry in leadership behaviors, practices, and decisions.
Directly supervises the daily operations for the CDI team who work onsite and remotely.
Communicates effectively with staff to ensure defined regional and/or system goals are met.
Maintains current knowledge of the MS-DRG system, CCs/MCCs, impact on quality, risk of mortality, severity of illness and CMI as well as ICD-10 coding systems and the guidelines related to Clinical Documentation Integrity.
Facilitates appropriate clinical documentation to ensure that the severity of illness, risk of mortality and level of services provided are accurately reflected in the health record.
Assists in overall quality, timeliness and completeness of the quality health record to ensure appropriate data, provider communication and quality outcomes. Serves as a resource for appropriate clinical documentation.
Responsible for scheduling and staffing assignments for the Clinical Documentation Specialist and Clinical Documentation Integrity Coordinator positions, facilitating management of personal time off and schedule change requests, assuring adequate staffing is in place. Monitors time and attendance system along with maintaining attendance records. Coordinates the work of external resources when used.
Along with the Clinical Documentation Integrity Coordinator, facilitates training of all new CDS hires.
Assists the Regional Manager, Clinical Documentation Integrity, in the recruitment, retention and supervision of CDI staff. Participates in the development of staff, including fostering teamwork, providing performance feedback, mentoring CDS and scheduling education. Collaborates with the Regional Manager, Clinical Documentation Integrity, on competency assessments, performance evaluations, counseling and/or conflict resolution.
Communicates with and educates physicians and all other members of the healthcare team regarding clinical documentation and monitors provider participation. Identifies learning opportunities for healthcare providers. Ensures that direct reports communicate, educate and engage with physicians and other members of the healthcare team regarding clinical documentation.
Collaborates with coding staff to assure documentation of discharge diagnoses and co-morbidities are a complete reflection of the patient’s clinical status and care. Ensures appropriate and accurate DRG assignment. Resolves all discrepancies in a courteous manner.
Demonstrates a thorough understanding of the MS-DRG system, CCs/MCCs, impact on quality and CMI as well as ICD-10 coding systems and the guidelines related to Clinical Documentation Improvement. Serves as a resource for the CDS team for any of the above.
Provides input for policy and procedure maintenance and development. Assists with the collection, aggregation and analysis of data. Collaborates in development and monitoring of performance to measure process outcomes, quality and productivity, and to ensure continual process improvements.
Ensures that direct reports remain current in coding guidelines and other regulatory directives that impact CDI performance. Ensures all compliance and regulatory standards are met.
Ensures that direct reports perform clinical validation as part of the review process and remain current on CDI strategies.
Maintains superuser level skill set in the use of 3M/360 and leverages technology and system reporting to improve CDI team efficiency and effectiveness. Monitors the CDI Dashboard and reporting to identify opportunities for improvement and areas of focus.
May perform CDI reviews to support program during high volume, short staffing periods.
Maintains a working knowledge of applicable Federal, State, and local laws and regulations, Trinity Health Corporate Integrity Program, Code of Ethics, as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical, and professional behavior.
(Pay Range: $47.2309-$70.8464)
MINIMUM QUALIFICATIONS
Bachelor’s Degree in Health Information Management, Healthcare related field or Nursing or equivalent in experience.
Must possess one of the below:
- Current Registered Nurse (RN) License
- Registered Health Information Administrator (RHIA)
- Registered Health Information Technician (RHIT)
- Certified Coding Specialists (CCS)
- Licensure as a physician assistant (PA) or Nurse Practitioner/Advanced Practice Nurse (NP/APN) or completion of medical school
- Certified Clinical Documentation Specialists (CCDS) or Certified Documentation Improvement Professional (CDIP) preferred
Minimum of five (5) years of current hospital clinical documentation integrity program experience is required. Two (2) or more years of current experience supervising hospital clinical documentation integrity program is required.
Must have thorough knowledge of CMS regulations, coding guidelines and DRG reimbursement.
Demonstrated knowledge of state and federal Hospital Acquired Conditions (HAC) and other applicable quality indicator codes (i.e. PSI, PPI, etc.).
Demonstrated, current expertise with 3M CDI Software. Working knowledge of Epic EMR preferred.
Must possess strong analytical and critical thinking skills in order to detect and resolve problems related to clinical documentation integrity.
Demonstrated ability to effectively supervise diverse and geographically dispersed teams both onsite and remote.
Excellent interpersonal skills with ability to build collaborative working relationships with clinical staff, finance and compliance.
Must possess strong written and verbal communication skills to effectively supervise clinical documentation integrity activities and communicate with a wide-ranging audience.
Intermediate computer skills required, including working knowledge of and experience using MS Word, Excel, Outlook and PowerPoint. Must be able to spend majority of work time utilizing a computer, monitor and keyboard.
Maintains professional attitude and ability to relate well with leadership, physicians, other care providers, colleagues and patients and others within the scope of the position.
Strong understanding of the Catholic health ministry in an evolving health care delivery system and changing reimbursement market.
Personal presence that is characterized by a sense of honesty, integrity, and caring as well as the ability to inspire and to motivate others to promote the philosophy, mission, vision, goals, and values of the Ministry.
PHYSICAL AND MENTAL REQUIREMENTS AND WORKING CONDITIONS
Ability to work in a fast-paced, multi-customer environment, with conflicting needs. May warrant varied and/or extended hours, with changes in workload and priorities to keep pace with the industry and advanced strategic priorities.
Must possess the ability to comply with enterprise policies and procedures.
Must be able to spend majority of work time utilizing a computer, monitor and keyboard.
The above statements are intended to describe the general nature and level of work being performed by persons assigned to this classification. They are not to be construed as an exhaustive list of duties so assigned.
Our Commitment
Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.
Originally posted on Himalayas