Manager for Clinical Documentation (RN)
FT – M-T (Hours:8am-4:30pm) Remote Work Available
Newark, DE
Are you an experienced CDI-Leader with a passion for clinical documentation integrity, teamwork, and performance improvement We are looking for a dynamic Clinical Documentation Manager with an active RN license to lead our Clinical Documentation Integrity Team. In this role, you will:
- Create, manage, and monitorall processes related to Clinical Documentation Integrity.
- Providedirection and leadershipto the Clinical Documentation Integrity Team.
- Ensureaccuracy and compliancein clinical documentation to support patient care and organizational goals.
SCOPE, PURPOSE, AND FREQUENCY OF CONTACTS:
Daily contact with Physicians, Clinical Documentation Specialists, Revenue Integrity, Health Information Management. Regular communication with Director and Medical Director(s).
PRINCIPAL DUTIES AND RESPONSIBILITIES:
- Proactively evaluates processes; recommends and implements action plan(s) for change; follows through to ensure effective, sustainable change. Participates in the development and implementation of new procedures and the review and revision of existing procedures.
- Identifies opportunities and takes action to build strategic relationships between one's area and other areas, teams, departments, and units to achieve business goals.
- Performs management responsibilities of selection, scheduling, supervision, retention, and evaluation of employees in the department. Provides development and mentoring of staff.
- Provides fair and leadership and communication to maintain a competent and engaged employee group by conducting regular department meetings to review policies, procedures, and operational matters.
- Completes performance appraisals, conducts new hire feedback sessions, and develops performance improvement plans where necessary.
- Provides timely guidance and feedback to help others strengthen specific knowledge/skill areas needed to accomplish a task or solve a problem.
- Provides clinical documentation integrity education to staff to keep team abreast of latest practices and to improve efficiency.
- Conducts periodic audits of queries and other clinical documentation integrity work products to ensure accuracy and efficiency
- Reviews clinical issues when appropriate with coding staff to assign a working DRG and/or clarification of documentation.
- Plans and organizes day-to-day department operations, schedule and activities. Sets priorities and functional standards, giving direction to staff as necessary to ensure the best possible delivery of service.
- Educates all internal customers, including physicians, on clinical documentation opportunities, supporting coding guidelines, as well as performance improvement methodologies.
- Uses and optimizes information systems to enhance operations; supports entity-specific performance improvement and data management/analysis functions.
- Monitors self and employee compliance with policies, procedures, compliance requirements, and mandatory system and departmental education.
- Improves the overall quality and completeness of clinical documentation by performing record reviews using clinical documentation guidelines.
- Assists with performing patient chart reviews during absences and when coverage is necessary.
- Assists in the development of department budget and ensures that the department operates in a cost-effective manner.
- Implements department strategies to achieve financial target and staffing needs, through optimizing productivity, supply/resource efficiency, and other areas according to department specifications.
- Develops and reports performance metrics for assigned work sections. Ensures section goals are met by employees.
- Seeks opportunities to identify developmental needs of self and staff and takes appropriate action.
EDUCATION AND EXPERIENCE REQUIREMENTS:
- Active Delaware RN license or Compact Licensure.
- Formal Clinical Training (RN) with professional licensure required
- Bachelor’s degree required; Three years’ experience in Clinical Documentation Integrity
- One year supervisory/management experience.
- Certified Clinical Documentation Specialist (CCDS) through the Association of Clinical Documentation Improvement Specialists preferred
- Maintains required documented hours of relevant continuing education related to licensure requirements.
- An equivalent combination of education and experience may be substituted.
KNOWLEDGE, SKILL, AND ABILITY REQUIREMENTS:
- Knowledge of DRG payor issues, appropriate DRG assignment alternatives, clinical documentation requirements, and referral policies and procedures
- Working knowledge of computer software: Word, Access, Excel, PowerPoint and clinical data packages.
- Knowledge of healthcare delivery and current clinical care.
- Knowledge of managing staff and processes.
- Skill in oral and written communication.
- Skill in initiation and maintenance of projects.
- Skill in analytical problem-solving techniques.
- Strong organizational skills.
- Ability to adjust to a changing work environment and demands necessitated by workload and program requirements.
- Ability to relate to others in a manner to gain confidence and establish support.
- Ability to maintain confidentiality in all aspects of related duties.
PHYSICAL DEMANDS:
Ability to ambulate with the hospital setting. Sitting, standing and lifting loads of 5-10 pounds
Ability to utilize computer equipment.
WORKING CONDITIONS:
Frequent travel to multiple sites as needed. Occasional exposure to office materials. Normal office environment.