RN - Manager Clinical Documentation Improvement - Registered Nurse

Job Summary

​The Clinical Documentation Improvement Program (CDI) is designed to improve the physician's documentation in the patient's medical record supporting the appropriate severity of illness, expected risk of mortality and complexity of care of the patient. The role of the Clinical Documentation Improvement Manager and Educator is to plan, manage and coordinate CDI practices to ensure consistency, meet corporate compliance guidelines, and to ensure appropriate and effective reimbursement in cooperation with key departments. Provides education to physician, physician service lines as needed to support hospital operations ensuring accurate and complete medical record. Works with Medical Staff as needed. Educates clinical documentation nurses by providing one-on-one and classroom clinical documentation and coding education to Clinical Documentation Improvement Specialists on issues related to the government mandated Inpatient Perspective Payment Program (MS-DRGs) and works collaboratively with the coding Supervisors, medical staff, mid-level providers, and other healthcare staff members. Collaborates and works closely with CDI Director and Leads from various platforms to identify specific areas and providers in need of education.

Job Duties

• ​Self-directed with ability to manage multiple areas through collaboration. Manages and acts as a resource to the personnel assigned as direct reports.
• Develops clinical data reporting and uses analytical assessment of data, data manipulation, and professionally articulate data outcomes to improve operations and report to various committees, including but not limited to the Utilization Management and Revenue Cycle committees.
• Plans, directs, educates, and assists with supervision of the CDI staff to ensure timely, accurate and complete processing of rendered services.
• Assumes responsibility for hiring, training and retention of employees.
• Establishes and monitors employee workflows, productivity, and quality. Evaluates staff performance.
• Develop and monitor internal key indicator metrics associated with CDI as it related to the revenue cycle and quality outcomes.
• Assists in setting annual department and individual performance goals for the upcoming year. Proactively review clinical documentation.
• Initiates recommendations for changes in classification, salary action, promotion, demotion, transfer, and termination.
• Assist with Interviews, selection and hiring of personnel.
• Effectively manages and oversees program performance regarding pertinent aspects of Revenue Cycle activity.
• Monitors and maintains an effective quality assurance and process improvement plan for clinical documentation processes. Plans and develops policies and procedures for system-wide CDI practices to meet Corporate Compliance guidelines and to ensure appropriate and effective reimbursement.
• Ensures overall integrity and exceptional performance of CDI staff through developed performance metric reporting.
• Ensures program knowledge and operational implementation of all related compliance, coding and documentation standards.
• Ensures program knowledge and operational implementation of teaching physician compliance guidelines and documentation standards as indicated by CMS and other contracts adopting these regulations.
• Develops and provides education on documentation opportunities and service line specific areas for improvement.
• Ensures quarterly periodic performance audits of staff to ensure compliance with all department policies and procedures.

Work is typically performed in a clinical environment. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job. Additional competencies and skills outlined in any department-specific orientation will be considered essential to the performance of the job related to that position.