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Manager, Clinical Documentation Improvement

4 months ago

Pleasanton, California, United States Stanford Health Care Full time

If you're ready to be part of our legacy of hope and innovation, we encourage you to take the first step and explore our current job openings. Your best is waiting to be discovered.

Day - 08 Hour (United States of America)

This is a Stanford Health Care job.

A Brief Overview
Uses clinical, coding and CDI expertise to perform daily operational management of the CDI program and CDI Staff. This position evaluates the adequacy and effectiveness of internal and operational controls designed to ensure that CDI processes and practices lead to appropriate execution of regulatory requirements and guidelines related to facility coding and CDI practices, including federal and state compliance standards.

This position plays a key role in leading the initiative for reporting quality of care outcomes and in obtaining complete, accurate and compliant documentation for appropriate reimbursement of services provided and capture of clinical outcome measures.

This position will work in concert with the CDI Director, and closely with physician leadership, Health Information Management coders and leadership, as well as Quality and Compliance leadership to support timely, accurate and complete documentation of clinical information and the success of the CDI Program Department.

This position will draft and manage CDI Program Department policies and processes. The CDI Manager will work with the CDI Director to implement CDI program strategy and collaboration with Quality, compliance and HIM to coordinate SHC provider documentation best practice.

Locations
Stanford Health Care

What you will do

  • Assists with the management of monthly, weekly and ad hoc reporting for CDI program performance, including that of CDI staff and providers. Assists in the performance of quality audits and analyzes the findings of performance audit information to build staff education, identify areas of individual and team performance opportunity and resolve as needed. Serve as a subject matter expert and authoritative resource on interpretation and application of CDI practices, coding rules and regulations and conducts risk assessments of potential and detected compliance deficiencies, as well as documentation improvement opportunities.
  • Acts as a consultant to quality managers, management team, medical staff and health care staff regarding core measure performance and clinical documentation opportunities.
  • Addresses abnormal ancillary test findings when they occur and queries physicians regarding the impact on patient care and DRG assignment.
  • Assists in monitoring and evaluating patient care in relationship to best practices while reviewing cases and patient records and makes any relevant recommendations to modify patient care.
  • Communicates effectively to facilitate positive working relationship and achieve desired outcomes.
  • Coordinates data collection related to patient care activities related to clinical outcome measures to provide feedback to clinical teams.
  • Coordinates the development of clinical documentation programs to improve the accuracy of documentation and the quality of patient care reported.
  • Coordinates the development of working sessions of multi-disciplinary teams in goal setting and problem solving.
  • Develops and implements medical-center-wide clinical documentation program.
  • Initiates physician interaction when ambiguous or conflicting information is in the medical record, providing guidance to Case Management, physicians, and hospital staff regarding documentation for correct coding and compliance necessary for increased Case Management Index (CMI), decreased Length of Stay (LOS), and optimal resource utilization.
  • Leads multidisciplinary and multi-departmental documentation initiatives to achieve strategic goals and objectives.
  • Manages Documentation Specialist Supervisor and Quality Specialists including activities such as goal setting, annual Performance Appraisal, coordinating scheduled time-off, allocating resources to cover the program throughout the hospital.
  • Performs monthly retrospective reviews for DRG verification with focus upon questionable DRGs focused OIG (Office of Inspector General) workplan and Centers for Medicare and Medicaid Services (CMS), also performing any organizational trends or patterns noted.
  • Serves as the departmental liaison with HIM and Compliance regarding clinical documentation and coded records.
  • Utilizes The International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) hospital coding policies and procedures, Federal and State coding reimbursement guidelines, and application of the Coding Clinic Guidelines to assign working Diagnostic Related Group (DRG), reviewing patient records throughout hospitalization that have been identified as focus DRG by regulatory agencies or the facility to ensure the codes are reported at the highest specificity.
  • Verifies appropriateness of assigned admission status communicating all discrepancies to Admitting Services for immediate correction.


Education Qualifications

  • Bachelor's degree in a work-related discipline/field (such as Nursing, Medicine, Health Information Management or similarly related) from an accredited college or university.


Experience Qualifications

  • Five (5) years of progressively responsible and directly related clinical work experience, with one (1) year of supervisory/management responsibility.


Required Knowledge, Skills and Abilities

  • Expertise in MSDRGs, ICD-9 coding and CDI practices required.
  • Expertise in CDI practices and knowledge distribution to multidisciplinary teams.
  • Proficiency with Microsoft Applications, including word processing, spreadsheets and presentation software.
  • Extensive knowledge and experience in reporting software and electronic medical record systems.
  • Demonstrated leadership ability.
  • Maintains working knowledge of Medicare/Medicaid rules and regulations regarding CDI, POA (present on admission), basic coding, as well as current trends and developments in the area of Clinical Documentation Improvement (CDI).
  • Ability to work with senior management, physicians, and medical center staff with various levels of education and experience.
  • Ability to develop and maintain strong, collaborative and supportive working relationships with CDI peers, physicians and other clinical professionals.
  • Must have demonstrated interpersonal, verbal and written communication skills in dealing with multidisciplinary teams and variety of ongoing activities.
  • Knowledge of computer systems and software used in functional area.
  • Knowledge of project management processes and systems.
  • Knowledge of statistical analysis and reporting practices pertaining to quality improvement and program evaluation.
  • Demonstrated organizational, project management skills.
  • Ability to be creative and innovative in a high volume work environment.
  • Ability to communicate effectively, both orally and in writing.
  • Ability to lead teams and produce project results within schedule and budget.
  • Ability to plan, organize, motivate, mentor, direct and evaluate the work of others.
  • Ability to provide leadership and influence others.
  • Ability to work effectively with individuals at all levels of the organization.
  • Ability to work independently.
  • Skilled and experienced in data analysis and qualitative reporting of results.
  • Skill in developing and delivering training and education to clinical, CDI and coding professionals regarding CDI practices, coding and documentation requirements.
  • Demonstrated organizational and critical thinking skills, ability to assess, evaluate and teach.
  • Skilled in adaptability and self-motivation in staying abreast of CDI practices, coding changes and clinical practices.
  • Demonstrated judgment and independent decision making.


Licenses and Certifications

  • CCDS - Cert Clinical Document Spec or
  • CCS - Certified Coding Specialist or
  • CRCR or
  • CPHQ - Health Care Quality Certification or
  • CCM - Certified Case Manager or
  • CPC and/or CCSP - Certified Professional Coder or
  • RN - Registered Nurse - State Licensure And/Or Compact State Licensure
  • CDIP – Clinical Documentation Improvement Practitioner

These principles apply to ALL employees:

SHC Commitment to Providing an Exceptional Patient & Family Experience

Stanford Health Care sets a high standard for delivering value and an exceptional experience for our patients and families. Candidates for employment and existing employees must adopt and execute C-I-CARE standards for all of patients, families and towards each other. C-I-CARE is the foundation of Stanford's patient-experience and represents a framework for patient-centered interactions. Simply put, we do what it takes to enable and empower patients and families to focus on health, healing and recovery.

You will do this by executing against our three experience pillars, from the patient and family's perspective:

  • Know Me: Anticipate my needs and status to deliver effective care
  • Show Me the Way: Guide and prompt my actions to arrive at better outcomes and better health
  • Coordinate for Me: Own the complexity of my care through coordination

#LI-RL1

Equal Opportunity Employer Stanford Health Care (SHC) strongly values diversity and is committed to equal opportunity and non-discrimination in all of its policies and practices, including the area of employment. Accordingly, SHC does not discriminate against any person on the basis of race, color, sex, sexual orientation or gender identity and/or expression, religion, age, national or ethnic origin, political beliefs, marital status, medical condition, genetic information, veteran status, or disability, or the perception of any of the above. People of all genders, members of all racial and ethnic groups, people with disabilities, and veterans are encouraged to apply. Qualified applicants with criminal convictions will be considered after an individualized assessment of the conviction and the job requirements.

Base Pay Scale: Generally starting at $ $90.62 per hour

The salary of the finalist selected for this role will be set based on a variety of factors, including but not limited to, internal equity, experience, education, specialty and training. This pay scale is not a promise of a particular wage.