临床文档完整性总监
Director, Clinical Documentation Integrity
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临床文档改进主管负责与临床文档领导团队合作并按照其指示，推动医疗体系临床文档改进计划的目标和工作成果。根据全系统举措和医院目标，制定年度CDI工作方案，并向CMO、CNO、CFO和质量负责人报告完成的活动。每年审查临床文档项目，确保符合州和监管指南。参与并积极支持临床文档的发展和改进，重点在于质量监控、临床文档专家持续能力的管理、项目增长和改进机会的识别。该职位为全系统临床文档改进团队提供教育支持，以提高患者病历的准确性和质量，确保诊断结果准确反映患者的临床状况和护理情况。临床文档改进主管负责为CDI团队提供新员工入职培训、指导和持续教育，以及为医生和特定服务线提供专业领域的教育。该职位作为CDI和供应商参与方面的专家，向临床护理转型高级副总裁汇报。
1. 识别临床文档改进问题，与医生、护士、编码人员和其他医疗团队成员建立良好沟通，能够独立解决这些问题。
2. 协助CDI团队满足教育需求、解决问题、时间管理和批判性思维技能的发展。
3. 在既定的临床和导师制模型中实施临床技能活动，监测数据趋势，并实施教育策略以确保符合质量标准。
4. 与职业发展部门合作，开发并提供新员工CDI入职和部门特定的培训项目及新CDI专家的胜任力要求，以及针对和提升CDI教育项目的课程。
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The Director, Clinical Documentation Improvement is responsible for progress towards goals and objectives for the Health System’s Clinical Documentation Improvement program, in collaboration and as directed by the Clinical Documentation leadership team. Based on System-wide initiatives and hospital goals will develop annual CDI workplans and report completed activities to CMO, CNO, CFO and Quality leaders. Annually review the Clinical Documentation program to ensure compliance to state and regulatory guidelines. Participates in and actively supports development and enhancement of clinical documentation, integrity practice with emphasis on quality monitoring, management of on-going competencies for Clinical Documentation Specialists, identification of programmatic opportunities for growth and improvement. This individual provides educational support to the systemwide clinical documentation improvement team to improve accuracy and quality in patient’s medical record and to ensure that diagnoses are an accurate reflection of the patient’s clinical status and care. The Director, CDI is responsible for providing new hire orientation, mentoring, and on-going education to the CDI team, as well as to provide specialty-specific education to physicians and targeted service lines. This individual will serve as a subject matter expert in CDI and provider engagement and reports to the AVP, Clinical Care Transformation.
1. Identify Clinical Documentation improvement issues and foster excellent communication with physicians, nurses, coding, and other members of the health care team to be able to work independently to resolve such issues.
2. Assists CDI team with educational needs, problem resolution, time management, and critical thinking skills development.
3. Implements clinical skills activities within established clinical and preceptorship models, monitors data trends, and implements educational strategies to ensure compliance with quality standards.
4. Collaborates with the Professional Development Department to develop and provide new hire CDI onboarding and department specific orientation program and competencies for new CDI Specialists, as well as educational programs to address and enhance the CDI team performance.
5. Maintains all department training materials, tools and/or records.
6. Develops and maintains department’s web-based collaborative platforms with education topics, performance outcomes by facility and key areas for CDI. Develops and publishes and maintains quarterly department newsletter.
7. Performs quality documentation audits, including chart review and query compliance of patient records, to ensure CDI Specialists and providers are compliant with applicable rules and regulations.
8. Provides mentoring and ongoing feedback to the CDI Team.
9. Engages physicians/providers on CDI topics and attends monthly service line meetings.
10. Develops and presents key CDI topics at all service line meetings.
11. Monitors CDI performance and tracks CDI team knowledge through bi-annual assessment tests.
12. Develops and maintains CDI assessment tests and develops education around topics missed.
13. Provides education to the CDI team related to the annual regulatory updates and changes.
14. Collaborates with Leadership and Medical Directors in the development and delivery of specialty specific education to physicians, departments, and specialties.
15. Evaluates second level review audits for areas of opportunity and develop education sessions to enhance the CDI team performance and/or physician documentation, both as a group and individually to ensure CDI success (IRR).
16. Represents the CDI team at various meetings as a clinical documentation improvement subject matter expert.
17. Coordinates with other departments (e.g., Coding/Quality/Care Management) regarding CDI initiatives to ensure efforts are synchronized, consistent, and effective.
18. Participates in performance improvement activities related to the operational processes for the Documentation Improvement Team, as well as related organizational/departmental goals.
19. Develops collaborative relationships and promotes teamwork with co-workers, physicians and other departments.
20. Collaborates with external CDI consultants to determine any education gaps or opportunities identified via external reporting, internal reporting, chart reviews, etc.
21. Incorporates protocols and standards of care into daily practice. Uses sound judgement, decision making criteria, and available resources for drawing conclusions and taking required action when teaching staff. Applies evidence-based practices and approaches, and solves problems using creativity and flexibility.
22. Conducts initial and follow-up concurrent reviews on targeted admissions for opportunities to clarify documentation in the medical record for accurate reflection of the acuity of the patient and justifying the level of care.
23. Coordinates with coding, HIM, Care Management, and other departments to achieve a record that reflects the acuity of the patient and level of care provided.
24. Reviews medical record concurrently for documentation not yet in the record but supported by clinical indicators.
25. Performs a thorough chart review to identify co-morbidities/complications, and documents these appropriately within the concurrent CDS worksheet. Discusses the appropriate principal diagnosis of the patient with the providers.
26. Displays leadership and accountability, serving as coach and role model and giving regular constructive and positive feedback
27. Communicates effectively, timely and in open and honest manner, sharing knowledge and skills with colleagues and others.
28. Displays mental and emotional effort required to function effectively in an environment with multiple and fluctuating priorities. Demonstrates professionalism, tact and diplomacy required for communication with providers, ancillary and nursing departments, facility, department, and administrative leaders.
29. Promotes continuous improvement of workplace safety and environmental practices.
30. Ensures compliance with all institutional policies and procedures including mandatory in-service employee health procedures, federal, state, regulatory and accrediting agencies standards.
31. Maintains professional knowledge by affiliating with professional and technical organizations, and participating in applicable continuing education programs, conferences, seminars, and workshops.
32. Adheres to University and unit-level policies and procedures and safeguards University assets.
This list of duties and responsibilities is not intended to be all-inclusive and may be expanded to include other duties or responsibilities as necessary.
Education: Bachelor’s degree in Healthcare Administration, Health Information Management, Informatics, Nursing, Leadership, Education, or related field; Master’s degree is highly preferred. Graduate degree preferred; Current FL RN License; FMG (MD) with extensive clinical and CDI experience will be considered.
Must maintain current one of the following:
Certified Documentation Specialist (CCDS); Clinical Documentation Improvement Professional (CDIP).
Certified Professional Coder (CPC); Certified Coding Specialist (CCS).
Experience:
Five (5) years of clinical experience in hospital setting; prior CDI experience required.
Thorough knowledge of ICD-9-CM, ICD-10-CM/PCS, APR DRG and MS DRG, Mortality, PSI and HAC required.
The University of Miami offers competitive salaries and a comprehensive benefits package including medical, dental, tuition remission and more.
UHealth-University of Miami Health System, South Florida's only university-based health system, provides leading-edge patient care powered by the ground breaking research and medical education at the Miller School of Medicine. As an academic medical center, we are proud to serve South Florida, Latin America and the Caribbean. Our physicians represent more than 100 specialties and sub-specialties, and have more than one million patient encounters each year. Our tradition of excellence has earned worldwide recognition for outstanding teaching, research and patient care. We're the challenge you've been looking for.
The University of Miami is an Equal Opportunity Employer. Applicants and employees are protected from discrimination based on certain categories protected by Federal law.
Job Status:
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StaffOriginally posted on Himalayas