Regional Director of Clinical Documentation Integrity | PAM Health Corporate

PAM Health Corporate Office • Enola, PA

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About The Position

The Regional Director of Clinical Documentation Integrity (RDCDI) is responsible for the support of the CDI program objectives as related to securing a thorough complete and accurate patient health record throughout our rehabs in an effort to achieve the correct reimbursement for resource utilization, the highest quality measures and outcomes, superior communication between providers and ultimately high patient satisfaction and quality care. The position will work closely with the key executive leaders and hospital leadership to ensure documentation within the medical record is comprehensive and complete and to create a support structure for achieving clinical and operational excellence in relation to CDI efforts. The RDCDI will assume responsibility to develop and provide continuing education of the CDI process. The role is responsible for reporting CDI metrics and developing supporting plans to address adverse trends identified. The position reports to the Corporate Director of CDI.

Requirements

• Graduation from a clinical program, RN, LPN, RT etc and/or Bachelors of Science in Health Information Management or related degree, Registered Health Information Administrator and/or Certified Coding Specialist certification.
• 5 years+ acute care experience with recent management or supervisory experience.
• Current licensure and/or certification

Nice To Haves

• CCDS or CDIP preferred. Must be willing to obtain CCDS or CDIP within first 2.5 years of employment

Responsibilities

• Develops and manages the Clinical Documentation functions/activities at each of the assigned hospitals.
• Acts as a subject matter expert for CDI within the organization and provides assistance with internal hospital initiatives as needed
• Performance of initial reviews, concurrent reviews and retrospective reviews (as appropriate) to ensure the CMG accurately reflects the principal diagnosis and comorbid conditions after study; Review of the working CMG and identification of conditions POA (present on admission), HAI, HAC, and potential CMG migrations.
• Ensure capture of documentation to support the SOI/ROM and resource consumption associated with the care on a concurrent basis and provides ongoing guidance for assigned hospitals
• Addresses CDI review opportunities to ensure the documentation is complete and accurate and provide education.
• Analyze clinical information to identify areas within the medical record that are conflicting, imprecise, incomplete, ambiguous, inconsistent, or illegible and queries on a concurrent basis to obtain clarification in the medical record in collaboration with hospital support
• Utilizes a compliant query process per guidelines and policy when conducting all queries; both written and verbal
• Monitor, track, trend and report of query rates as related to type, response rates, associates provider, and outcomes
• Collaborates with hospital staff and providers to promote complete and accurate clinical documentation and to correct negative data trends; acts as a consultant to key stakeholders when additional information is needed
• Provides CDI education to providers, clinical staff, or departments one on one, during staff meetings or departmental meetings as needed, either remotely or on location.
• Educates internal staff on clinical documentation and coding guidelines
• Maintains the highest level of customer service via courtesy, compassion and positive communication
• Promotes the Mission and Vision of PAM Health within the work environment and the community
• Respects dignity and confidentiality by adherence to all applicable policies and procedures
• Demonstrate compliance with all federal, state and local laws; rules and government
• Comply with the Employee Code of Conduct and all other Hospital Institutional Policies and Procedures

Benefits

• competitive pay
• generous paid benefit time
• excellent insurance options
• opportunities for professional growth through our Education Advancement Program

What This Job Offers

• Job Type: Full-time
• Career Level: Director
• Number of Employees: 5,001-10,000 employees