Job Description

\rJob Description \r

Directs the activities of the Clinical Documentation Improvement (CDI) department. Facilitates modifications to clinical documentation to ensure accurate depiction of the level of clinical services and patient severity through extensive concurrent interaction with physicians, nursing staff and other caregivers, case management, and medical records coding staff.

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Job Responsibility

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Leads a Clinical Documentation group by communicating with and developing staff members, and building consensus for programs and goals that support a business, function or geographic area.
Develops and articulates a short-term strategic vision for areas of responsibility.
Ensures clinical documentation, including modifications, accurately reflect the level of service rendered and severity of illness in compliance with government and other regulations for all patients.
Oversees a system to identify admissions with specific diagnosis / DRG classifications or other categories of admissions; ensures chart review within 48-72 hours of admission to meet criteria.
Ensures periodic documentation review with cases that have a length of stay greater than 3 days; ensures follow up reviews of clinical documentation are conducted by CDS staff to evaluate whether issues discussed and clarified with the physician have been recorded in the patients chart.
Ensures recommendation of possible refinement of principal diagnosis based on Clinical data on admission and concurrently during the hospital stay to facilitate appropriate DRG assignment; interacts with physician regarding documentation appropriate to diagnosis and support appropriate levels of severity of illness and risk of mortality.
Monitors CDI performance regularly by way of CDI software and performs routine query audits to ensure compliance; serves as a resource to Physicians / Case Managers and other key professional staff in matters relating to published DRG information.
Works with medical records, finance and physician groups to develop systems to facilitate complete documentation for data reporting purposes; develops and monitors strategic operating goals, objectives and budget; reports operational performance, justification and/or corrective action.
Develops and manages direct reports; oversees the development and management of indirect reports.
Builds and maintains productive inter/intra departmental and vendor work relationships to optimize operations.
Oversees compliance with government and agency regulations.
Performs related duties as required. All responsibilities noted here are considered essential functions of the job under the Americans with Disabilities Act. Duties not mentioned here, but considered related are not essential functions.

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Job Qualification

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Bachelor of Science in Nursing required.
Current License to practice as a Registered Professional Nurse in New York State required, plus specialized certifications as needed.
8-12 years of relevant experience and 7+ years of leadership / management experience, required.