Clinical Documentation Manager

Registry Ally • Orange, CA

9d • Onsite

About The Position

The Clinical Documentation Manager is responsible for the leadership and management of the Clinical Documentation Improvement (CDI) Program. This position is accountable for budgeting, planning and monitoring budget variances, etc. Ensures standards of unit operations are in compliance with all state and federal healthcare regulatory agencies ACDIS & AHIMA guidelines for compliant query, as well as hospital policies and procedures. Incumbent facilitates the improvement in the overall quality, completeness, and accuracy of medical record documentation through comprehensive review and evaluation of the medical record. Proactively seeks clarification from physicians and other healthcare providers when further specificity is needed to ensure. The CDI Manager educates senior leaders and physicians on documentation guidelines on an ongoing basis.

Requirements

• Active and unrestricted California RN or Nurse Practitioner License
• Master’s Degree in Nursing or other healthcare related field
• Minimum 7 years of clinical RN experience
• 5 years’ experience as a CDI Specialist
• Previous lead or supervisory experience
• Familiarity with Utilization Review criteria
• Knowledge of CMS, Joint Commission, CADP, and other regulatory and compliance requirements
• CDI Credential (CCDS, CDIP)
• Electronic Health Record experience 3M, Epic
• Knowledge of ICD-10 CM and CPT coding
• Ability to establish and maintain effective working relationships across the Health System
• Ability to maintain a work pace appropriate to the workload
• Must demonstrate customer service skills appropriate to the job
• Complete understanding of acuity levels for specific patient populations
• Excellent written and verbal communication skills in English
• Strong clinical knowledge with ability to interpret clinical documentation

Nice To Haves

• Previous experience with comprehensive chart / record review
• Knowledge of patient safety strategies
• CCS or CPC Coding Credential
• Knowledge of quality improvement methodologies
• Knowledge of University and medical center organizations, policies, procedures and forms

Responsibilities

• Leadership and management of the Clinical Documentation Improvement (CDI) Program
• Budgeting, planning and monitoring budget variances
• Ensuring standards of unit operations are in compliance with all state and federal healthcare regulatory agencies ACDIS & AHIMA guidelines for compliant query, as well as hospital policies and procedures
• Facilitating the improvement in the overall quality, completeness, and accuracy of medical record documentation through comprehensive review and evaluation of the medical record
• Proactively seeks clarification from physicians and other healthcare providers when further specificity is needed to ensure
• Educating senior leaders and physicians on documentation guidelines on an ongoing basis

Benefits

• Highly Competitive Salary
• Excellent Benefits

What This Job Offers

• Job Type: Full-time
• Career Level: Manager