Manager Clinical Documentation

POSITION SUMMARY:

The Clinical Documentation Manager is responsible for ensuring that clinical documentation within the health system accurately reflects the services and care provided to patients and is consistent with the seven criteria for high quality clinical documentation. The manager acts as a coordinator of physician clinical documentation, coding and reimbursement processes in working towards agreed upon quality and productivity targets for all services in the system.

Position: Manager

Department: Clinical Documentation

Schedule: Full Time

ESSENTIAL RESPONSIBILITIES / DUTIES:

A. Interdisciplinary

The Clinical Documentation Manager functions primarily as an interdisciplinary manager focusing primarily on ensuring physician documentation is complete, accurate and representative of the care provided to the system’s patients. To that end, the manager will have access to physicians and clinical staff to participate in and assist in ensuring the ongoing documentation improvement effort is successful. The manager will report directly to the Director of Clinical Documentation Coding Integrity.

The manager will:

• Coordinate and manage the activities of the Clinical Documentation Integrity Department (CDI specialists and CDI validation specialist) as well as inter-related departments and collaborative vendors involved in the clinical documentation integrity process.

• Ensure that the Clinical Documentation Integrity Department is continuously used primarily as a vehicle to promote documentation improvement for accurate reimbursement on an ongoing basis.

• Oversee and manage the documentation improvement efforts of clinical documentation specialists, the CDI validation specialist, and related collaborative vendors involved in the clinical documentation integrity process.

• Coordinate and provide ongoing education to healthcare professionals on documentation concerns, proper coding, medical terminology and treatment processes.

• Work with finance department on continuous case mix modelling and assessment.

• Participate in the rejections and claims review process with patient accounting to ensure both compliance and accurate reimbursement.

• Track trends in documentation concerns and implementing corrective action.

• Oversee and manage coding activities within the Clinical Documentation Integrity Department to ensure accurate, consistent and compliant coding for all services. Conduct quality and compliance reviews to validate coding and DRG & APC assignments, implementing education and corrective action as needed.

• Create and update documentation tools, processes, procedures, and work flows on an ongoing basis.

• Collaborate with partnered vendors to identify and explore opportunities for improvement within the Clinical Documentation Integrity Department. Implement education and plans to capitalize on identified opportunities.

• Provide guidance, support and expertise to the CDI specialists and CDI validation specialist.

• Work with CDI validation specialist to identify, coordinate, and implement CDI specialist ongoing education and feedback based on identified opportunities for improvement via auditing.

• Review and analyze denial claims and denial data to provide support in denial prevention strategies via clinical validation query process and education to CDI specialists.

• Contributes to departmental and organizational quality performance goals, including auditing mortality and readmission cohorts to identify opportunities for improvement. Coordinate and implement CDI specialist education based on identified opportunities.

B. Inpatient Services

• Track case mix through both retrospective and concurrent means

• Provide feedback to clinical documentation specialists, CDI validation specialist, coders, physicians and other clinicians and vendors involved in the documentation improvement effort.

• Recommend and implement corrective actions when deficiencies are identified.

C. Benchmarks

• Measure the effectiveness of documentation tools.

• Trend and quantify the effectiveness of clinical documentation specialists and related involved vendors efforts. Evaluate the success of concurrent documentation improvement on an ongoing basis.

D. Personnel Management

• Works with Human Resources and department managers on the selection of qualified candidates for employment following all policies, guidelines, and applicable laws.

• Responsible for effective personnel management including training, directing, mentoring and instilling a commitment to quality and excellence.

• Coordinates, manages, and oversees new employee on boarding and training.

• Monitors productivity and performance to identify and evaluate program/ department strengths and training opportunities in relation to operational effectiveness.

• Conducts employee performance evaluations and disciplines when appropriate to include termination, with appropriate supportive documentation as per established policy.

• Encourages staff and personally advances professional growth and development through participation in educational programs and workshops and maintaining knowledge of industry standards and practices.

• Monitor and manage employee time reporting and attendance via Kronos.

• Oversee and manage staffing to meet departmental needs.

• Oversee and manage staff earned time usage.

(The above statements in this job description are intended to depict the general nature and level of work assigned to the employee(s) in this job. The above is not intended to represent an exhaustive list of accountable duties and responsibilities required).

JOB REQUIREMENTS

REQUIRED EDUCATION AND EXPERIENCE:

• Bachelors degree in nursing, health information management or related field and at least five years (5) years of experience in clinical documentation, or equivalent combination of education and experience, are required.

PREFERRED EDUCATION AND EXPERIENCE:

• Master's degree preferred

• Previous management experience preferred

CERTIFICATES, LICENSES, REGISTRATIONS REQUIRED:

• RN license required if nursing degree is held.

CERTIFICATES, LICENSES, REGISTRATIONS PREFERRED:

• CCDS, CDIP

KNOWLEDGE, SKILLS & ABILITIES (KSAs):

• Familiarity with physician practices, health information, case management or related healthcare discipline

• Familiarity with all government health care reimbursement systems

• Have experience working collaboratively with diverse groups in a health care environment

• Demonstrated success in interacting effectively with physicians

• Excellent speaking, writing and teaching skills

• Proficient with standard Microsoft programs (i.e. MS Word, Excel, PowerPoint, Outlook) and web browsers.

• Ability to analyze large amounts of data to identify trends.

• Ability to provide direction and development to employees by coaching, identifying training needs, assigning progressively challenging projects, and assisting in career development planning.

• Demonstrate advanced knowledge of clinical documentation integrity practices, policies, workflows, and analysis.

Equal Opportunity Employer/Disabled/Veterans

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