System Director, Clinical Documentation Integrity
About The Position
The System Director, Clinical Documentation Integrity (CDI) oversees best practices in clinical documentation to accurately represent patient complexity for all outcomes. The CDI team is part of the Department of Quality and Safety, the System Director reports to the Chief Quality Officer (CQO). The System Director is responsible for a cohesive clinical documentation strategy across the health system to ensure an accurate reflection of severity of illness, resources, and care for quality outcomes and to maximize reimbursement. This includes all inpatient clinical entities – Academic adult population; pediatrics - Benioff Children’s Hospitals; community setting - St Mary’s and St Francis Hospitals; and ambulatory for Medicare Advantage risk adjustment. The Director is a strategic dyad partner with four Medical Directors for the respective clinical entities - setting the vision and standards through the program’s foundation of structure-process-outcomes. The System Director develops partnerships with clinical services and multi-disciplinary teams to ensure precise documentation reflects complex care management. This includes partnering with clinical leaders for standard clinical definitions by service line experts templated into the EMR. In collaboration with the Medical Directors, the Director provides guidance and interpretation of outcomes to supports service line initiatives. The System Director collaborates with the health information management (HIM) leadership for Coding to ensure documentation maximizes DRG assignment for reimbursement and accuracy in quality outcomes. The CDI System Director closely follows team performance related to process and outcome metrics, provider engagement and supports a very significant ROI. The Director follows quality outcomes - case mix index (CMI), patient safety indicators (PSI), hospital acquired conditions (HAC), sepsis and mortality outcomes. The System Director is a strategic leader throughout the organization as the subject matter expert for the True North quality goals. The CDI System Director collaborates with other DOQS leaders and is a multi-disciplinary strategic partner for process improvement opportunities across the health system. Clinical Documentation Integrity (CDI) is a team within the Department of Quality & Safety that reviews provider documentation and facilitates accurate representation of patients treated across UCSF Health. Through collaborative relationships with clinical teams, CDI supports best practices in documentation improvement strategies with an emphasis on severity of illness, medical complexity and quality in the medical record. CDI closely follows case mix index, risk adjusted outcomes and mortality ratings.
Requirements
- Subject matter expert for the True North quality goals.
- Experience in clinical documentation integrity.
- Experience in quality outcomes, case mix index (CMI), patient safety indicators (PSI), hospital acquired conditions (HAC), sepsis and mortality outcomes.
- Experience in health information management (HIM) and Coding.
- Experience in EMR templating.
- Experience in risk adjustment.
- Experience in medical record review.
Nice To Haves
- Experience in academic adult population, pediatrics, and community settings.
- Experience in ambulatory settings for Medicare Advantage risk adjustment.
Responsibilities
- Oversees best practices in clinical documentation to accurately represent patient complexity for all outcomes.
- Responsible for a cohesive clinical documentation strategy across the health system to ensure an accurate reflection of severity of illness, resources, and care for quality outcomes and to maximize reimbursement.
- Sets the vision and standards through the program’s foundation of structure-process-outcomes as a strategic dyad partner with four Medical Directors.
- Develops partnerships with clinical services and multi-disciplinary teams to ensure precise documentation reflects complex care management.
- Partners with clinical leaders for standard clinical definitions by service line experts templated into the EMR.
- Provides guidance and interpretation of outcomes to support service line initiatives in collaboration with Medical Directors.
- Collaborates with health information management (HIM) leadership for Coding to ensure documentation maximizes DRG assignment for reimbursement and accuracy in quality outcomes.
- Closely follows team performance related to process and outcome metrics, provider engagement and supports a very significant ROI.
- Follows quality outcomes - case mix index (CMI), patient safety indicators (PSI), hospital acquired conditions (HAC), sepsis and mortality outcomes.
- Acts as a strategic leader throughout the organization as the subject matter expert for the True North quality goals.
- Collaborates with other DOQS leaders and is a multi-disciplinary strategic partner for process improvement opportunities across the health system.
- Reviews provider documentation and facilitates accurate representation of patients treated across UCSF Health.
- Supports best practices in documentation improvement strategies with an emphasis on severity of illness, medical complexity and quality in the medical record through collaborative relationships with clinical teams.
- Closely follows case mix index, risk adjusted outcomes and mortality ratings.
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What This Job Offers
Job Type
Full-time
Career Level
Director
Education Level
No Education Listed
