Inpatient Clinical Documentation Integrity Manager - FT - Days - MSS

Memorial Healthcare

3d • Onsite

About The Position

Responsible for managing the daily operations of inpatient clinical documentation integrity consistent with administrative, medical, ethical, regulatory and governmental requirements. Oversees improvement in the overall quality, completeness and accuracy of medical record documentation to ensure patient's acuity of care and severity of illness are accurately reflected in the medical record. Provides education to physicians and other care providers on documentation guidelines. Effectively manages Clinical Documentation Integrity Specialists (CDIS) covering Memorial Healthcare System (MHS) acute care facilities ensuring provider clarifications meet regulatory requirements.

Requirements

• Accredited Program (Required)
• Registered Health Information Technician (RHIT) - State of Florida (FL)
• Three (3) years of clinical documentation integrity management experience.
• Graduate of an accredited school of HIM or nursing.
• Must be a Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Coding Specialist (CCS), or Registered Nurse (RN).
• Requires critical thinking skills, effective written and verbal communication skills, effective time management, decisive judgment and the ability to work with minimal supervision.
• Must be able to work in a stressful environment and take appropriate action.
• Ability to accurately determine the correct ICD-10-CM/PCS codes and MSDRG or APRDRG to hospitalized inpatients under CDI review.
• Proficient in basic computer skills including Microsoft Office applications, utilizing a computerized encoder and electronic medical record system.
• Ability to work well with physicians and other allied health staff.
• Demonstrates professional responsibility and fosters teamwork.

Responsibilities

• Maintains thorough knowledge of ICD-10CM/PCS coding principles and guidelines; possesses substantial knowledge of MSDRG and APRDRG reimbursement systems and guidelines for compliant provider documentation clarification.
• Serves as an expert resource for all CDI and coding staff.
• Maintains strict adherence to patient confidentiality according to MHS Standards and regulatory requirements.
• Works with Medical Director, HIM and MHS Chief Medical Officers (CMOs) to collaborate with the medical staff to ensure timely completion of physician clarifications to capture appropriate documentation.
• Generates CDI reports for MHS monthly operating review (MOR), facility Chief Financial Officers and CMOs to monitor provider clarification and response rates, impact on case mix index (CMI) and reimbursement.
• Determines work assignments, monitors employee work activities and schedules all training needs.
• Assures appropriate CDI coverage to perform initial and follow-up medical record reviews.
• Monitors staff compliance with CDI quality and productivity standards; advises employees of monthly quality and productivity results.
• Monitors electronic HIM CDI work queues daily.
• Provides ongoing, one-on-one, or group education related to documentation integrity and compliance to physicians, extenders, nursing, clinical dieticians, wound care specialists, physical therapists and other allied health professionals as needed.
• Works closely with the Auditor, Clinical Documentation Integrity (CDI) Compliance to determine educational topics for staff training.
• Participates in MHS system-wide Quality and Patient Safety work groups to facilitate accurate and complete provider documentation.
• Oversees CDI collaboration with Quality Management and Population Health specialists to advise of Patient Safety Indicators (PSIs), Hospital Acquired Conditions (HACs) and Bundled Payments for Care Improvement (BPCI) admit diagnoses/Diagnosis Related Groups (DRGs).
• Performs all other duties as assigned.
• Manages staff relations including performance management, staff satisfaction, and conflict management.
• Performs and oversees scheduling, recruitment, payroll, and updating clinical documentation integrity (CDI) policies and procedures.
• Evaluates and counsels CDI specialists' work performance, attendance, annual reviews, work schedule and paid leave requests.
• Conducts timely performance reviews within MHS required due dates.
• Orients and mentors new CDIS to MHS applications, workflow and Health Information Management (HIM) policies and procedures.

What This Job Offers

• Job Type: Full-time
• Career Level: Manager
• Education Level: Associate degree