Department: 200734 Clinical Documentation
Facility: Renown Regional Medical Center
Reno, NV
Schedule: Full Time - Eligible for Benefits
Shift: Day
Hours: 0800-1700
Job Details:
  • Position Purpose:

    Under the direction of the Vice President of Revenue Cycle, the Director of Clinical Documentation Improvement has the overall responsibility for facilitating the development, implementation, growth and maintenance of the program through the Renown Network.  Provides training and ongoing education for staff complete, appropriate documentation of the medical record to achieve accurate inpatient coding, DRG assignment, and severity documentation. Directs the processes and personnel responsible for concurrent review of physician and ancillary documentation to identify complications, co morbidities, and opportunities for improved documentation. 

     

    Provides leadership of the retro query process managed by the Physician Liaison.  Provides physician education and consultation to improve the accuracy of documentation in in-patient records.  Develops documentation and query tools in cooperation with HIM and medical care teams.  Along with Decision Support, develops a database work-lists and reports to support the initiative.  Provides CDI reports as needed

     

    The position requires research, problem resolution, & specialized knowledge in the area of Medicare, and the supporting documentation required for compliant physician documentation.  This position is responsible for maintaining departmental standards of excellence as established by Renown Standards of Conduct.

    Nature and Scope:

    The Clinical Documentation Improvement Director will ensure staff in this department is kept current on regulations and procedures and has the tools they need to perform their duties at optimal levels.  This department and its staff must be able to maintain a high level of knowledge of regulations and timeliness to ensure compliance with all processes.

     

    KNOWLEDGE, SKILLS & ABILITIES:

     

    1.     Provides leadership of the CDI Department. 

     

    2.     Provides CDI training.  Provides on-going education based upon audit findings and changes in coding   requirements.  Facilitates joint continuing education to staff and physicians as needed.

     

    3.     Provides on-going feedback to Staff regarding the quantity and quality of concurrent queries.  Provides suggestions as to opportunities for additional queries.  Addresses questions regarding severity levels of specific cases along with coding / HIM.  Along with HIM, develops mechanism for auditing quality of CDI queries on an on-going basis.

     

    4.     Provides physician education and consultation to improve the accuracy of documentation on in-patient records.  Participates in new resident training sponsored by the Medical Staff Office, compliance training, and rotating residency program education sponsored by individual medical departments as requested.  Serves as liaison as needed regarding documentation and query issues/strategies.  Provides suggestions to Physician liaison regarding informal documentation education/communication to be accomplished during retro query meetings.  Participates in ad hoc CDI consultation/education sessions requested by specific medical departments or work-groups and HIM.

     

    5.     Develops work-plans for the retro query audits with HIM.  Provides leadership to the retro query process including scheduling, communication and other strategies.  Facilitates collection of information needed from HIM or auditing group in order to conduct retro queries.  Requests support as needed in addressing any barriers to achievement of work-plans.  Communicates physician feedback obtained during retro query sessions in order to address any physician concerns/needs.  Meets established deadlines for Retro Query closeout.

     

    6.    Develops, implements, and evaluates documentation and query tools.  Conducts annual review of tool content based upon changes in ICD-9 codes and revises or develops new tools as needed.  Based upon audit results provides feedback to medical teams regarding template development/revision which could enhance the accuracy of in-patient documentation.  Works with IT to place appropriate tools and documentation references on the facility Intranet for access by medical teams, HIM coders and auditors.

     

    7.     Develops, implements, and evaluates physician query guidelines along with HIM Team.  Participates on HIM Team in development, implementation, and evaluation of generic and service specific coding and documentation guidelines.

     

    8.      Ensures collaboration between Health Information Management (HIM), Revenue Cycle, and CDI Team for                knowledge sharing and educational purposes on all CDI matters.

     

    9.     Along with Decision Support, develops plans for database reports to support the CDI initiative and work-lists to streamline work while directing the data harvesting and report writing.   Develops distribution plan for service specific CDI reports.  Provides and interprets CDI reports as needed in administrative or clinical forums.

     

    10.   Maintains and interprets master CDI spreadsheet data for trends, accuracy and QA.

     

    11.   Consults on clinical data interpretation for facility wide quality improvement, database and compliance issues as requested.

     

    12.   Performs other duties as required.

     

    This position does not provide patient care.  

     

    The foregoing description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills and efforts or work conditions associated with the job. It is intended to be an accurate reflection of the general nature and level of the job.

    Minimum Qualifications:  Requirements - Required and/or Preferred

    Education:

    Bachelors Degree preferred. However, 10 years experience in acute hospital billing leadership will be considered in lieu of the degree.  Must have working-level knowledge of the English language, including reading, writing and speaking English.

    Experience:

    Five years of experience working with documentation to meet quality, financial and regulatory requirements is required.  

    Prior supervisory or leadership experience is required.

    License(s):

    Ability to obtain and maintain a State of Nevada Registered Nurse license.

    Certification(s):

    Certified Clinical Documentation Specialist (CCDS) is required within one year of hire.

    Computer / Typing:

    Must be proficient with Microsoft Office Suite, including Outlook, PowerPoint, Excel and Word and have the ability to use the computer to complete online learning requirements for job-specific competencies, access online forms and policies, complete online benefits enrollment, etc.



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