Manager - Clinical Documentation Integrity

Memorial Healthcare

23h • Onsite

About The Position

The Clinical Documentation Integrity Manager oversees daily department operations in compliance with administrative, medical, ethical, regulatory, and governmental standards. This role leads initiatives to improve the quality, completeness, and accuracy of medical record documentation, ensuring that patient acuity and severity of illness are accurately reflected. The Manager provides education to physicians and other healthcare providers on documentation requirements and best practices, while effectively supervising staff across Memorial Healthcare System (MHS) acute care facilities. Additionally, this role ensures provider documentation clarifications meet all applicable regulatory and compliance requirements.

Requirements

• Bachelors (Required)
• Registered Health Information Technician (RHIT) - State of Florida (FL)
• 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.
• A minimum of three (3) years of clinical documentation integrity management experience.
• Bachelor’s degree in Health Information Management or a clinical degree such as Nursing, MD, DO, or a foreign medical degree (e.g., MBBS, MBBCh)
• CCS, RHIA, RHIT, RN (FL or Compact), or licensed physician (MD/DO) required

Nice To Haves

• CDI credentials (CDIP or CCDS) preferred

Responsibilities

• 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.
• 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.

Benefits

• We encourage candidates to talk to their Memorial Healthcare System recruiter to discuss actual pay rates, during the hiring process.

What This Job Offers

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