Manager for Clinical Documentation Integrity (CDI)

FT – M-F (Hours:8am-4:30pm) Remote Work with onsite presence when needed.

Newark, DE

Are you an experienced CDI-Leader with a passion for clinical documentation integrity, teamwork, and performance improvement?    We are looking for a dynamic Clinical Documentation Manager with an active RN license to lead our Clinical Documentation Integrity Team. In this role, you will:

• Create, manage, and monitor  all processes related to Clinical Documentation Integrity.
• Provide direction and leadership  to the Clinical Documentation Integrity Team.
• Ensure accuracy and compliance  in clinical documentation to support patient care and organizational goals.

SCOPE, PURPOSE, AND FREQUENCY OF CONTACTS:

Daily contact with Physicians, Clinical Documentation Specialists, Revenue Integrity, Health Information Management.  Regular communication with Director and Medical Director(s).

PRINCIPAL DUTIES AND RESPONSIBILITIES:

• Proactively evaluates processes; recommends and implements action plan(s) for change; follows through to ensure effective, sustainable change. Participates in the development and implementation of new procedures and the review and revision of existing procedures.
• Identifies opportunities and takes action to build strategic relationships between one's area and other areas, teams, departments, and units to achieve business goals.
• Performs management responsibilities of selection, scheduling, supervision, retention, and evaluation of employees in the department. Provides development and mentoring of staff.
• Provides fair and leadership and communication to maintain a competent and engaged employee group by conducting regular department meetings to review policies, procedures, and operational matters.
• Completes performance appraisals, conducts new hire feedback sessions, and develops performance improvement plans where necessary.
• Provides timely guidance and feedback to help others strengthen specific knowledge/skill areas needed to accomplish a task or solve a problem.
• Provides clinical documentation integrity education to staff to keep team abreast of latest practices and to improve efficiency.
• Conducts periodic audits of queries and other clinical documentation integrity work products to ensure accuracy and efficiency
• Reviews clinical issues when appropriate with coding staff to assign a working DRG and/or clarification of documentation.
• Plans and organizes day-to-day department operations, schedule and activities. Sets priorities and functional standards, giving direction to staff as necessary to ensure the best possible delivery of service.
• Educates all internal customers, including physicians, on clinical documentation opportunities, supporting coding guidelines, as well as performance improvement methodologies. 
• Uses and optimizes information systems to enhance operations; supports entity-specific performance improvement and data management/analysis functions.
• Monitors self and employee compliance with policies, procedures, compliance requirements, and mandatory system and departmental education.
• Improves the overall quality and completeness of clinical documentation by performing record reviews using clinical documentation guidelines.
• Assists with performing patient chart reviews during absences and when coverage is necessary.
• Assists in the development of department budget and ensures that the department operates in a cost-effective manner.
• Implements department strategies to achieve financial target and staffing needs, through optimizing productivity, supply/resource efficiency, and other areas according to department specifications.
• Develops and reports performance metrics for assigned work sections. Ensures section goals are met by employees.
• Seeks opportunities to identify developmental needs of self and staff and takes appropriate action.

EDUCATION AND EXPERIENCE REQUIREMENTS:

• Active Delaware RN license or Compact Licensure. 
• Formal Clinical Training (RN) with professional licensure required
• Bachelor’s degree required; Three years’ experience in Clinical Documentation Integrity
• One year supervisory/management experience. 
• Certified Clinical Documentation Specialist (CCDS) through the Association of Clinical Documentation Improvement Specialists preferred
• Maintains required documented hours of relevant continuing education related to licensure requirements.
• An equivalent combination of education and experience may be substituted.

KNOWLEDGE, SKILL, AND ABILITY REQUIREMENTS:

• Knowledge of DRG payor issues, appropriate DRG assignment alternatives, clinical documentation requirements, and referral policies and procedures
• Working knowledge of computer software: Word, Access, Excel, PowerPoint and clinical data packages.
• Knowledge of healthcare delivery and current clinical care.
• Knowledge of managing staff and processes.
• Skill in oral and written communication.
• Skill in initiation and maintenance of projects.
• Skill in analytical problem-solving techniques.
• Strong organizational skills.
• Ability to adjust to a changing work environment and demands necessitated by workload and program requirements.
• Ability to relate to others in a manner to gain confidence and establish support.
• Ability to maintain confidentiality in all aspects of related duties.

PHYSICAL DEMANDS:

Ability to ambulate with the hospital setting.  Sitting, standing and lifting loads of 5-10 pounds

Ability to utilize computer equipment.

WORKING CONDITIONS:

Frequent travel to multiple sites as needed.  Occasional exposure to office materials.  Normal office environment.