Manager, Clinical Documentation Improvement

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The Manger of Clinical Documentation Integrity (CDI) provides daily leadership and oversight of the CDI Team. Under the direction of the CDI Director, works in association with other leaders, CDI Specialists, coders, quality specialists, data analysts, providers, and other members of the healthcare team to ensure accurate clinical documentation in the medical record. The CDI Manager maintains oversight of all phases of the CDI process to ensure compliance, accuracy, care quality, and severity are reflected. Oversees the daily workflow of the CDI staff while applying CDI expertise. 

Supervises all phases of the clinical documentation process and applies CDI review expertise to ensure compliance, accuracy, specificity, and severity captures are obtained consistently by all reviewers. Support staff as the key resource for clinical documentation and coding. 

Maintain concurrent and retrospective review expertise to ensure accuracy, specificity, and severity captures are obtained consistently by all reviewers.

Develops policies, systems, and processes for CDI, updating as needed.

Identifies areas of improvement within CDI and other related functional areas and initiates solutions.​

Serves an escalation point for CDI-Coder DRG discrepancies and query requests.

Promotes effectiveness of the CDI program through leadership and management skills. 

Ensures accuracy and completeness of information used for measuring and reporting CDI, physician, and hospital outcomes.

Generates and analyzes data reports for monitoring performance and identification of opportunities for improvement; makes recommendations based upon data analysis.

Ensure that key performance metrics are met and provide proactive intervention as needed. This is accomplished through data analysis, direct observation, expert review of medical records, and daily staff interactions.

Works with vendors and/or internal stakeholders as CDI subject matter expert to analyze issues and develop solutions. 

Provides education to the medical staff and the healthcare team regarding clinical documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies.

Manages personnel, ensuring effective team building and conflict resolution.

Conducts/oversees CDI review quality and query compliance audits. Implements educational strategies to ensure compliance with quality standards.

Regulates staffing in accordance with fluctuating workload and shifting departmental priorities. 

Conducts HR management activities including, but not limited to, interview, hiring, orientation and training, performance evaluations, performance enhancement plans and/or disciplinary actions. 

Perform duties and conduct interpersonal relationships in a manner that promotes a team approach and collaborative work environment with physicians, CDI staff, coders, and leaders.

Assumes responsibility for professional development through participation at workshops, conferences, and/or in-services and maintains appropriate records of participation.

 Understands and disseminates reports to appropriate administrative personnel indicating performance metrics and impact of the CDI program.

Collaborate with CDI Specialists, Educators, Auditors, Director, and Physician Champions/Advisor regarding any physician engagement concerns and action plan recommendations. 

Performs expert CDI chart reviews and complex second-level reviews (concurrent and retrospective) as needed.

Assists with special projects and other duties as deemed necessary by CDI Director, and/or other department leadership. 

Seeks guidance from the Director and/or upper management for unusual or unanticipated circumstances that require deviation from policy/practice or allocation of funds to resolve.

Actively participates in meetings, departmental and hospital committees, and assigned task force groups.

Communicates effectively, timely and in open and honest manner, sharing knowledge and skills with colleagues and others

Displays mental and emotional effort required to function effectively in an environment with multiple and fluctuating priorities. Demonstrates professionalism, tact and diplomacy required for communication with providers, ancillary and nursing departments, department and administrative leaders.

Serves as a resource to Physicians and other key healthcare staff in matters relating to DRG information and/or clinical documentation principles. 

Minimum Qualifications:

Education:

Bachelor’s degree in nursing required (BSN/BS/BA)

Graduate Degree Preferred in Healthcare Administration, Informatics, Nursing, Leadership, Education or related field; 

FMG (MD) with extensive clinical and CDI experience will also be considered.

Certification and Licensing:

Current and Active Registered Nurse license

CDI certification required: Certified Documentation Specialist (CCDS) by ACDIS or Certified Clinical Documentation Improvement Practitioner (CDIP) by AHIMA

Coding certification preferred: Certified Professional Coder (CPC) by AAPC or Certified Coding Specialist (CCS) by AHIMA

Experience:

At least four (4) years acute care clinical documentation improvement specialist experience required.

Thorough knowledge of ICD-10-CM/PCS, APR DRG and MS DRG, Mortality, AHRQ PSI, CMS HAC, Vizient, U.S. News & World Report, and CDI best practices required.

Excellent written and verbal communication skills; ability to write concisely and effectively when communicating with providers.

Knowledge of age-specific patient needs and the elements of disease processes and related procedures.

The University of Miami offers competitive salaries and a comprehensive benefits package including medical, dental, tuition remission and more.

UHealth-University of Miami Health System, South Florida's only university-based health system, provides leading-edge patient care powered by the ground breaking research and medical education at the Miller School of Medicine. As an academic medical center, we are proud to serve South Florida, Latin America and the Caribbean. Our physicians represent more than 100 specialties and sub-specialties, and have more than one million patient encounters each year. Our tradition of excellence has earned worldwide recognition for outstanding teaching, research and patient care. We're the challenge you've been looking for.

Patient safety is a top priority. As a result, during the Influenza ("the flu") season (September through April), the University Of Miami Miller School Of Medicine requires all employees who provide ongoing services to patients, work in a location (all Hospitals and clinics) where patient care is provided, or work in patient care or clinical care areas, to have an annual influenza vaccination. Failure to meet this requirement will result in rescinding or termination of employment.

The University of Miami is an Equal Opportunity Employer - Females/Minorities/Protected Veterans/Individuals with Disabilities are encouraged to apply. Applicants and employees are protected from discrimination based on certain categories protected by Federal law. Click for additional information.

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