Manager (RN) Clinical Documentation Integrity - Atrium Health Carolina Medical Center Hybrid FT Days

Overview

PRIMARY PURPOSE

Provides daily direct operational leadership and oversight of the Clinical Documentation Integrity (CDI) program and CDI nursing staff at assigned hospitals. Ensures Advocate Health CDI practice standards are systemically applied at all Advocate Health sites as assigned. Responsible for consistent achievement of budgeted site CDI financial benefit targets and other CDI key result areas at assigned hospital sites. Adapts departmental staffing plans and resources to meet operational challenges. Provides onboarding and ongoing development of site CDI staff. Serves as the CDI expert for all assigned hospital sites, ensuring compliant, accurate and timely clinical documentation in the medical record, supporting the coding process of accurate code assignment. Provides ongoing communication and education for site executives & clinicians related to program performance, practice patterns and opportunities for improvement. Completes expert second level CDI case reviews, leverages data, coaches staff and clinicians, and influences to continually improve results and impact key performance indicators. Collaborates regularly with site executives, site physicians, site quality leaders, coding professionals, physician advisors, and others to promote ongoing collaboration, communication and problem solving. Regularly participates in enterprise CDI meetings & CDI practice development and improvement; occasionally leads enterprise projects within CDI division.

Major Responsibilities

• Provides direct management oversight of the daily operations of the clinical documentation program at assigned sites.
• Responsible for interviewing, hiring, orientation, and ongoing competency assessment of CDI staff in collaboration with the Director of CDI operations. 
• Conducts performance evaluations, salary reviews, and corrective action for the CDI staff. Approves and monitors staff schedules, paid time off, and timecards to ensure continuity of services. Monitors proficiency of each sites’ CDI staff and includes action plans to improve deficiencies. Responsible for team building and conflict resolution
• Completes expert CDI second level reviews to identify missed query opportunities, ensure compliant CDI practice, assure data validation; provides coaching, consultation or corrective action as appropriate based on findings.
• Creates and runs reports for the CDI program in order to effectively evaluate both individual associate and overall site program performance. Analyzes data and information to discern root causes of performance gaps using key data and reports. Regularly review individual site successes and improvement opportunities with the Director of CDI Operations and other key stakeholders.
• Identifies and discusses overall and individual physician documentation trends with Director of CDI Operations and site Medical Staff Leadership as appropriate with a documented improvement plan with strategies and educational needs identified.
• Serves as an internal consultant on clinical documentation opportunities. Acts as an expert resource for CDI program, including support for mismatch resolution on challenging cases, intervention with physicians when necessary, dissemination and interpretation of key regulatory requirements and changes, etc.
• Actively participates in site performance improvement processes as appropriate.
• Collaborates with other departments such as Coding, compliance, quality and finance to support site and organizational goals and CDI strategic plan.
• Supports, actively participates in performance improvement activities and projects for the enterprise CDI program, including the review and modification of policies, procedures, and processes.
• Consults, communicates and organizes key ongoing education for site clinicians and executives.
• Responsible for personal professional growth. Participates in professional organizations, maintains licensures and certification as required, maintains effective working relations with both internal and external customers, maintains required competencies and assumes responsibility for personal development and maintenance of ongoing knowledge of current clinical documentation standards and regulatory requirements through participation at workshops, conferences and or in services and maintaining records of participation.
• Ensures CDI program operates under compliant CMS, AHIMA, and ACDIS practice standards and codes of ethics. Collaborates with compliance to ensure the enterprise CDI program meets all state and federal guidelines.
• Performs human resources responsibilities for staff which include interviewing and selection of new employees, promotions, staff development, performance evaluations, compensation changes, resolution of employee concerns, corrective actions, terminations, and overall employee morale.
• Develops and recommends operating and capital budgets and controls expenditures within approved budget objectives.
• Responsible for understanding and adhering to the organization's Code of Ethical Conduct and for ensuring that personal actions, and the actions of employees supervised, comply with the policies, regulations and laws applicable to the organization's business.

MINIMUM JOB REQUIREMENTS

Education

Bachelor’s Degree in Nursing required

Certification / Registration / License

Active Registered Nurse license required. Certification in clinical documentation integrity required; Certification in Healthcare Quality also preferred; issued by the state in which the team member practices 

Work Experience

Typically requires 5 years of related clinical documentation integrity experience. Includes 1 year of supervisory or project management experience in a clinical environment. 

Knowledge / Skills / Abilities

• Ability to prioritize and organize work. Able to respond to multiple requests simultaneously.
• Ability to travel and work across multiple sites as assigned.
• Effective communication skills.
• Utilization of critical thinking in timely decision making.
• Knowledge of MS office products.
• Demonstrates leadership skills.
• Knowledge of Medicare Part A and B guidelines and how they impact DRG assignment.
• Knowledge of Regulatory environment.
• Ability to prioritize independently.
• Competent in Advocate Health preferred Performance Improvement methodologies

PHYSICAL REQUIREMENTS AND WORKING CONDITIONS

PREFERRED JOB REQUIREMENTS

Education

Master's Degree in Nursing or Master's Degree in Health Care Administration preferred

Certification / Registration / License

Certification in Healthcare Quality preferred

DISCLAIMER

All responsibilities and requirements are subject to possible modification to reasonably accommodate individuals with disabilities.

This job description in no way states or implies that these are the only responsibilities to be performed by an employee occupying this job or position.  Employees must follow any other job-related instructions and perform any other job-related duties requested by their leaders.