Documentation Manager jobs in Gastonia, NC

Overview

Job Summary

The Manager of Clinical Documentation Integrity is responsible for the clinical and administrative leadership of documentation excellence initiatives. Responsible for staff management and development, quality, service excellence, workplace experience and financial outcomes.  This clinical position uses clinical/nursing knowledge and understanding of national coding guidelines and standards of compliance to improve overall quality and completeness of clinical documentation within the patient electronic medical record using a multidisciplinary team process. Exhibits expertise associated with advanced certification in CDI. Partners with Medical and other leaders to achieve goals to improve quality of care metrics. Assumes accountability as delegated by the Director.

Essential Functions:

• Oversees Clinical Documentation Integrity (CDI) program; monitors and maintains the timeliness of workflow, productivity, and quality of the site CDI program; develops and monitors implementation of site departmental goals/objectives and supports the performance improvement process in conjunction with the Clinical Documentation Director.
• Aligns department with system strategy, vision, mission, and goals
• Ensures competency of Clinical Documentation Specialist staff by conducting on-going reviews and skills assessments; provides action plans and timely constructive feedback, as needed, to enhance staff development; leads hiring, training, and performance management processes for all site-based CDI employees; coaches, mentors and empowers employees to complete tasks by providing information and support

• Performs audits to ensure that the assigned MS-DRG that most accurately reflects the severity of illness of the patient based upon the clinical evidence documented in the record. Reviews clarifications for compliance and assignment of proper impacts. Tracks and trends program compliance to ensure adherence to all CMS regulations regarding DRG assignment

• Supports the CDI program by generating and analyzing reports and data to identify opportunities for continuous growth and improvement; provides feedback to individual staff and other facility-based leadership. Develops and implements action plans when appropriate.
• Monitors CDI computer applications and assists IAS with quarterly updates and testing as appropriate.
• Demonstrates knowledge and understanding of severity based DRG systems; All-Patient Refined and Medicare Severity (APR-DRG), Medical Severity Diagnostic Related Group System (MS-DRG) and   Hierarchical Condition Categories (HCC).
• Interacts with the physician advisor, attending physicians, and/or other designated members of the healthcare team when applicable and follow-up is warranted per escalation guideline.
• Works with other departments such as coding, corporate compliance, quality, and finance to support Corporate Goals.
• Participates in the ongoing education of providers and other healthcare team members to identify medical record documentation improvement opportunities employing conflict resolution skills, as necessary.
• Ensures that all written requests to physicians for additional documentation support Corporate Compliance policies.
• Serves as a clinical leader and systems expert resource.

Physical Requirements

Works in a remote office type setting, extensive walking throughout the facility. Prolonged periods of sitting reviewing medical records and documentation. Repetitive wrist motion and occasional lifting of 10-20 pounds. Intact sight and hearing with or without assistive devices are required. Ability to speak English fluently and write in understandable terms.

Education, Experience and Certifications

Bachelor of Science in Nursing Required. Master’s Degree in Nursing or Health-related field required. Current RN license or temporary license as a Registered Nurse Petitioner in the state in which you work and reside or if declaring a National License Compact (NLC) state as your primary state of residency, meet the licensure requirements in your home state; or for Non-National License Compact states, current RN license or temporary license as a Registered Nurse Petitioner required in the state where the RN works. Additional education, training, certifications, or experience may be required within the department. Minimum of five years direct clinical nursing experience required. Minimum of two years of experience in leadership and clinical documentation improvement preferred.