Clinical Documentation Integrity Manager Responsible for management of the Clinical Documentation Integrity (CDI) team. Develops policies, procedures, and guidelines to standardize CDI workflow. Recruits, hires and develops team members. Maintains a continuing education program to keep current with clinical documentation standards, government regulations, and coding changes. Meets budget requirements and participates in budget preparation. Provides education to physician, physician offices as needed to support hospital operations ensuring accurate and complete medical record. Works closely with the inpatient coding team.
Education
Bachelors Degree - Required
Experience
2-3 Years CDI specialist - Required
License & Certification
Professional Nursing License with State of Practice - Required
Certified Clinical Documentation Specialist (CCDS) - Required
Core Job Functions
Reports key performance indicator metrics for CDI as related to the revenue cycle and to quality measures. Establishes CDI goals and monitors progress. Proactively reviews clinical documentation to ensure compliance with Joint Commission standards. Creates an environment that promotes evidence based practices and encourages the use of research to improve operational processes.
Initiates education with respect to the needs for and formatting of clear documentation with the medical staff, provides education to the inpatient coding team on clinical evidence, and establishes ongoing training for the CDI team focused on compliant queries, recognizing quality measures, and DRG assignment. Collaborates with Coding and Denials in response to documentation denials or appeals on audited claims and provides feedback to CDI, coders, or physicians as appropriate to proactively prevent reoccurrence of denials.
Maintains current competency with 3M 360 processes and works with the 3M team to enhance the functioning of the CDI workflow including optimizing worklists and actively test new features. Involves staff participation in making recommendations for improvements to 3M. Responsible for testing CDI processes whenever there is an update. Creates and uses 3M reports and creates ad hoc reports.
Analyze clinical status of patient, current treatment plan and past medical history and identifies potential gaps in physician documentation. Conduct follow up reviews of clinical documentation. Initiate and maintain interactions with physicians on a concurrent basis to address the need for more detailed information in the medical record.
Interviews, hires, promotes, and evaluates co-worker performance based on established standards. Meets regularly with staff to improve processes and communicate information. Collaborates with staff to plan adequate coverage for daily operations.
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