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.