Clinical Documentation Integrity Manager - Days

Full Time (80 Hours Biweekly)

Day Shift

General Summary

Under the general supervision of the Senior Director-Health Information Management (HIM), oversees the performance of the Clinical Documentation Integrity Specialists (CDIS). Facilitates improvement in overall quality, completeness, and accuracy of medical record documentation at all entities (inpatient and outpatient) within the WellSpan Health System.  Obtains appropriate clinical documentation through extensive interaction with providers, nursing staff, other patient care givers, and health information management coding staff to ensure the clinical documentation reflects the level of service rendered to patients and is complete and accurate.

Duties and Responsibilities:

1. Serves as a resource for the organization regarding compliant documentation standards and guidelines.
2. Educates all internal customers on compliant documentation opportunities, as well as performance improvement methodologies.
3. Demonstrates knowledge of DRG payer issues, prospective payment systems, case mix analysis, coding guidelines as they pertain to CDI, documentation opportunities, clinical documentation requirements, quality review requirements, and referral policies and procedures.
4. Ensures team members are capturing the accuracy and completeness of clinical information used for patient care, measuring and reporting physician and hospital outcomes including evidence-based measures, HCC capture, and appropriate reimbursement.
5. Conducts trend analysis to identify patterns and variations in documentation practices and initiates corrective action for resolution of any problems with documentation practices.
6. Collaborates with Case Management, Quality, and Patient Safety departments to maintain an accurate portrayal of organization reports that utilize physician documentation and codes.
7. Collaborates with Coding, Defense Audits, and Corporate Compliance in response to documentation denials/appeals on audited claims, documentation initiatives, query policies, and provider and staff education.
8. Reviews clinical issues with coding staff to assign a working DRG and reconcile it against the final DRG.
9. Develops a collaborative team and facilitates teamwork among CDI and HIM coding team members.

The following are common expectations:

10. Leads and manages CDI team, directing productivity and staffing, maintaining job descriptions and performance standards, developing key performance indicators, and monitoring aggregate reporting of departmental performance utilizing LEAN/performance improvement processes.
11. Manages employees through recruitment and retention, performance evaluations and discipline, and time and attendance record approval.  Interviews, selects, hires, guides, monitors training, and administers disciplinary actions within areas of responsibility.
12. Enhances professional growth and development through participation in professional associations, educational programs, current literature, in-service meetings, and workshops.
13. Maintains working knowledge of software utilized by the CDI team and collaborates with vendors to maintain recommended best practices and identify opportunities for improvement.
14. Provides outstanding service to all customers; fosters teamwork; and practices fiscal responsibility through improvement and innovation.

Qualifications:

  Note:                         Other combinations of formal education, training and experience may be considered.

  Minimum Education      Bachelor's Degree

  Preferred Education      Master’s Degree

  Minimum Experience     3 - 5 years Clinical Documentation Integrity

  Pref Field Of Expertise   Clinical Documentation Integrity

  Req Cert/Registration    CCDS or CDIP; RN, MD, DO or APP (PA or CRNP) with current license in PA

  Physical Demands         Mostly sedentary work

                                  Occasional prolonged standing/walking