Director, Clinical Documentation Integrity

University of Miami•Hialeah, FL

18h•Onsite

About The Position

The Director, Clinical Documentation Improvement is responsible for progress towards goals and objectives for the Health System’s Clinical Documentation Improvement program, in collaboration and as directed by the Clinical Documentation leadership team. Based on System-wide initiatives and hospital goals will develop annual CDI workplans and report completed activities to CMO, CNO, CFO and Quality leaders. Annually review the Clinical Documentation program to ensure compliance to state and regulatory guidelines. Participates in and actively supports development and enhancement of clinical documentation, integrity practice with emphasis on quality monitoring, management of on-going competencies for Clinical Documentation Specialists, identification of programmatic opportunities for growth and improvement. This individual provides educational support to the systemwide clinical documentation improvement team to improve accuracy and quality in patient’s medical record and to ensure that diagnoses are an accurate reflection of the patient’s clinical status and care. The Director, CDI is responsible for providing new hire orientation, mentoring, and on-going education to the CDI team, as well as to provide specialty-specific education to physicians and targeted service lines. This individual will serve as a subject matter expert in CDI and provider engagement and reports to the AVP, Clinical Care Transformation.

Requirements

Bachelor’s degree in Healthcare Administration, Health Information Management, Informatics, Nursing, Leadership, Education, or related field
Master’s degree is highly preferred.
Graduate degree preferred
Current FL RN License
FMG (MD) with extensive clinical and CDI experience will be considered.
Must maintain current one of the following: Certified Documentation Specialist (CCDS); Clinical Documentation Improvement Professional (CDIP). Certified Professional Coder (CPC); Certified Coding Specialist (CCS).
Five (5) years of clinical experience in hospital setting
Prior CDI experience required.
Thorough knowledge of ICD-9-CM, ICD-10-CM/PCS, APR DRG and MS DRG, Mortality, PSI and HAC required.

Responsibilities

Identify Clinical Documentation improvement issues and foster excellent communication with physicians, nurses, coding, and other members of the health care team to be able to work independently to resolve such issues.
Assists CDI team with educational needs, problem resolution, time management, and critical thinking skills development.
Implements clinical skills activities within established clinical and preceptorship models, monitors data trends, and implements educational strategies to ensure compliance with quality standards.
Collaborates with the Professional Development Department to develop and provide new hire CDI onboarding and department specific orientation program and competencies for new CDI Specialists, as well as educational programs to address and enhance the CDI team performance.
Maintains all department training materials, tools and/or records.
Develops and maintains department’s web-based collaborative platforms with education topics, performance outcomes by facility and key areas for CDI. Develops and publishes and maintains quarterly department newsletter.
Performs quality documentation audits, including chart review and query compliance of patient records, to ensure CDI Specialists and providers are compliant with applicable rules and regulations.
Provides mentoring and ongoing feedback to the CDI Team.
Engages physicians/providers on CDI topics and attends monthly service line meetings.
Develops and presents key CDI topics at all service line meetings.
Monitors CDI performance and tracks CDI team knowledge through bi-annual assessment tests.
Develops and maintains CDI assessment tests and develops education around topics missed.
Provides education to the CDI team related to the annual regulatory updates and changes.
Collaborates with Leadership and Medical Directors in the development and delivery of specialty specific education to physicians, departments, and specialties.
Evaluates second level review audits for areas of opportunity and develop education sessions to enhance the CDI team performance and/or physician documentation, both as a group and individually to ensure CDI success (IRR).
Represents the CDI team at various meetings as a clinical documentation improvement subject matter expert.
Coordinates with other departments (e.g., Coding/Quality/Care Management) regarding CDI initiatives to ensure efforts are synchronized, consistent, and effective.
Participates in performance improvement activities related to the operational processes for the Documentation Improvement Team, as well as related organizational/departmental goals.
Develops collaborative relationships and promotes teamwork with co-workers, physicians and other departments.
Collaborates with external CDI consultants to determine any education gaps or opportunities identified via external reporting, internal reporting, chart reviews, etc.
Incorporates protocols and standards of care into daily practice. Uses sound judgement, decision making criteria, and available resources for drawing conclusions and taking required action when teaching staff. Applies evidence-based practices and approaches, and solves problems using creativity and flexibility.
Conducts initial and follow-up concurrent reviews on targeted admissions for opportunities to clarify documentation in the medical record for accurate reflection of the acuity of the patient and justifying the level of care.
Coordinates with coding, HIM, Care Management, and other departments to achieve a record that reflects the acuity of the patient and level of care provided.
Reviews medical record concurrently for documentation not yet in the record but supported by clinical indicators.
Performs a thorough chart review to identify co-morbidities/complications, and documents these appropriately within the concurrent CDS worksheet. Discusses the appropriate principal diagnosis of the patient with the providers.
Displays leadership and accountability, serving as coach and role model and giving regular constructive and positive feedback.
Communicates effectively, timely and in open and honest manner, sharing knowledge and skills with colleagues and others.
Displays mental and emotional effort required to function effectively in an environment with multiple and fluctuating priorities. Demonstrates professionalism, tact and diplomacy required for communication with providers, ancillary and nursing departments, facility, department, and administrative leaders.
Promotes continuous improvement of workplace safety and environmental practices.
Ensures compliance with all institutional policies and procedures including mandatory in-service employee health procedures, federal, state, regulatory and accrediting agencies standards.
Maintains professional knowledge by affiliating with professional and technical organizations, and participating in applicable continuing education programs, conferences, seminars, and workshops.
Adheres to University and unit-level policies and procedures and safeguards University assets.