Responsible for the leadership, planning, daily operation, employee relations, maintenance of standards of performance, and customer satisfaction for Clinical Documentation Improvement program (CDI) at New Hanover, and Cape Fear and Women and Children’s Hospitals under the direction of the Director of Clinical Resource Services. The CDI program includes providing concurrent medical record review for defined patient populations to identify opportunities to improve accuracy of practitioner documentation; collaborating with Case Managers, Outcomes, Managers, and Coding Department to assure documentation is clinically appropriate and reflective of current CMS standards; providing education to medical staff regarding documentation.
1.Directs hospital based Clinical Documentation Improvement efforts provided by RN Documentation Specialist that focus on capturing documentation that accurately reflects the severity of illness and risk of mortality for hospital patients.
2.Responsible for the daily operations of the Documentation Specialist, ensuring that policies, practices, procedures and standards are followed.Makes regular rounds to support the Documentation Specialist in their role, serves as an expert resource.
3.Participates in and supports the attainment and analysis of data to minimize variations in staff work flow and physician documentation patterns to optimize the capture of accurate clinical documentation.
4.Prepares regular reports for the Director to assist in monitoring the effectiveness of the Documentation Specialist’s individual performance and the impact of the overall program.
5.Participates in planning and providing education to the medical staff and service lines related to documentation to assure medical record is reflective of accurate medical diagnoses, complications and co-morbidities.
6.Collaborates with Coding Department when discrepancy in medical record is identified and reviews medical record to provide clinical feedback for accurate coding of procedural codes, ICD-9-CM diagnosis or DRG.
7.Hires and retains competent and service excellence oriented staff.
8.Ensures staffing is sufficient and employees are adequately trained.Responsible for evaluation and disciplinary process.
9.Works collaboratively with the Case Management team to support compliance with Medicare and Medicaid regulations.
10.In coordination with the Director, establishes and monitors departmental objectives relative to the
11.Maintains budget for program operations within established guidelines.
12.Participates in performance improvement activities related to the operational processes for the
Documentation Improvement Program as well as related organizational/departmental goals.
13.Develops collaborative relationships and promotes team work with co-workers and other departments.
14.Organizes and performs work responsibilities effectively and efficiently.
15.Demonstrates effective leaderships and communication skills.