SSM Health

System Dir-RN, Clinical Documentation Improvement

Posted on

February 19, 2025

Job Type

Full-Time

Role Type

Leadership / Management

License

RN

State License

Compact / Multi-State

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Company Description

Job Description

Coordinates the overall activities of the program and staff system-wide. Facilitates improvement in the overall quality, completeness, and accuracy of medical record documentation through extensive interaction with clinicians and overseeing managers. Ensures clinical documentation accurately reflects the services and care provided to the patients and is consistent with the criteria for high quality clinical documentation. Acts as a coordinator of physician clinical documentation, coding, and reimbursement processes in working towards agreed upon quality and productivity metrics for all services in the system. Utilizes clinical documentation improvement (CDI) data to analyze diagnosis related group (DRG) assignment, quality documentation and financial impact of the program, and measures the effectiveness of coding and evaluates concurrent documentation improvement. Creates management reports identifying key metrics of the CDI program.

Requirements

EDUCATION: Graduate of accredited school of nursing Bachelor’s Degree EXPERIENCE: Seven years’ with five in leadership PHYSICAL REQUIREMENTS: Frequent lifting/carrying and pushing/pulling objects weighing 0-25 lbs. Frequent sitting, standing, walking, reaching and repetitive foot/leg and hand/arm movements. Frequent use of vision and depth perception for distances near (20 inches or less) and far (20 feet or more) and to identify and distinguish colors. Frequent use of hearing and speech to share information through oral communication. Ability to hear alarms, malfunctioning machinery, etc. Frequent keyboard use/data entry. Occasional bending, stooping, kneeling, squatting, twisting and gripping. Occasional lifting/carrying and pushing/pulling objects weighing 25-50 lbs. Rare climbing. REQUIRED PROFESSIONAL LICENSE AND/OR CERTIFICATIONS State of Work Location: Illinois Registered Professional Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR) State of Work Location: Missouri Registered Nurse (RN) Issued by Compact State Or Registered Nurse (RN) - Missouri Division of Professional Registration State of Work Location: Oklahoma Registered Nurse (RN) Issued by Compact State Or Registered Nurse (RN) - Oklahoma Board of Nursing (OBN) State of Work Location: Wisconsin Registered Nurse (RN) Issued by Compact State Or Registered Nurse (RN) - Wisconsin Department of Safety and Professional Services

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Responsibilities

Serves as leader of the organization’s clinical documentation improvement (CDI) program system-wide, by providing input relative to documentation improvement processes and resources. Updates leadership on facility coding/documentation improvement efforts. May require regular travel or onsite work as directed. Implements CDI productivity standards for each region/ministry. Develops system-wide goals, objectives, policies, and procedures. Ensures compliance with business unit policies, procedures and governmental/accreditation regulations. Oversees CDI education and assists with educational initiatives for both CDI and clinical staff. Supports and implements new CDI technologies and initiatives designed to improve overall documentation integrity. Provides strategic planning and recommendations for the development and enhancement of the CDI program. Develops relationships with internal resources, consultants, auditors, and physician advisors to develop and achieve the established plan. Collaborates with coding director and other department heads to accomplish related organizational goals. Analyzes internal and publicly reported data and implements changes that will improve documentation. Manages CDI resources and process outcomes accountable to performance standards. Directs and trains staff on risk adjusted/mortality reviews per system-wide workflows utilizing third-party models. Monitors and tracks the progress of CDI program through key metrics and provides reports to leadership. Analyzes regional CDI quality and productivity reports working with CDI educator to deploy quality reviews and education for CDI associates to improve performance. Analyzes CDI physician reports working with physician leads to develop and deploy opportunities for documentation improvement. Maintains an on-going awareness of Centers for Medicare & Medicaid Services (CMS) requirements related to clinical documentation and provides feedback to clinical staff regarding these requirements during the concurrent record review process. Implements a management system that is customer-focused, encourages efficiency and automation, and drives performance. Recruits, engages, develops, leads, and manages assigned staff. Applies the existing body of evidence-based practice and scientific knowledge in health care to nursing practice, ensuring that nursing care is delivered based on patient’s age-specific needs and clinical needs as described in the department's scope of service. Works in a constant state of alertness and safe manner. Performs other duties as assigned.

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