System Dir-RN, Clinical Documentation Improvement

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.

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.