Director - Clinical Documentation Integrity - FT - Days - MTC

The Director of Clinical Documentation Integrity (CDI) is primarily responsible for overseeing clinical documentation integrity processes, practices, and operations for all hospitals at the Healthcare System level. Serves as the Memorial Healthcare System’s (MHS) primary subject matter expert and authoritative resource on the interpretation and application of CDI practices. This role uses clinical, coding and CDI expertise to perform daily management of the CDI program. This leader is involved in the direction and education of all phases of the CDI Specialist role, from onboarding new hires to covering new service lines.

Responsibilities

Overseeing clinical documentation integrity processes, practices, and operations for all hospitals at the Healthcare System level; Serving as the primary subject matter expert on the interpretation and application of CDI practices; Performing daily management of the CDI program; Responsible for physician education to improve the accuracy of documentation in patient medical records; Serves as the liaison between the medical staff and CDI staff regarding documentation and query issues and strategies; Evaluates the adequacy and effectiveness of internal and operational controls designed to ensure CDI practices are compliant with regulatory requirements; Leads and implements provider documentation strategies by working closely with Medical Director of Centralized UR-HIM, CMOs, Hospitalist Physician leaders, CFOs, Vice President - Chief Medical Information Officer (CMIO), HIM leaders, and medical staff; Monitors the success of the team by analyzing and trending KPIs to include CMI and SOI shifts; Determines the needed staffing for each facility and budgets accordingly; Directs staff training and develops a training plan for all new CDI staff members; Ensures compliant query practice following AHIMA and ACDIS guidelines; Provides leadership to the CDI staff and chairs/facilitates weekly CDI meetings; Approves hiring, training, education, policies, procedures, and makes budget recommendations related to CDI operations; Leads and coordinates efforts between the CDI software vendor and IT; Analyzes CDI operational reports and dashboards monthly and interprets reports to leadership.

Requirements

Bachelors in Health Information Management or relevant field of study (Required); Certified Coding Specialist (CCS) - American Health Information Management Association (AHIMA); Registered Health Information Administrator (RHIA) - American Health Information Management Association (AHIMA); Registered Health Information Technician (RHIT) - State of Florida (FL); Registered Nurse Compact License (RN LICENSE COMPACT) - Compact RN Multistate; Registered Nurse License (RN LICENSE) - State of Florida (FL); Five (5) years of CDI management experience; Equivalent work experience may substitute for education requirement: Associate's degree plus seven (7) years of CDI management experience or High school diploma plus nine (9) years of CDI management experience; CDIP (AHIMA Certified Documentation Integrity Practitioner) or CCDS (ACDIS Certified Clinical Documentation Specialist) or CDIP credential; Business Acumen; Concern for Quality; Develop Relationships; Lead Through Vision; Manage Performance; Critical thinking skills, effective communication, decisive judgment, and the ability to build and foster positive relationships; Ability to lead others and take appropriate action when required; Advanced clinical expertise and extensive knowledge of complex disease processes and understanding of pathology and physiology of diseases in an inpatient setting; Expertise in MSDRGs, APRDRGs, ICD10 coding, Rehab IRFPAI, and CDI practices; Proficiency with Microsoft applications, including spreadsheets and presentation software; Extensive knowledge of reporting software and EMRs; Ability to work with senior leadership, physicians and MHS staff with various levels of education and experience; Ability to collaborate and create supportive working relationships with physicians and other clinical professionals; Knowledge of project management processes; Ability to plan, organize, motivate, mentor, direct and evaluate the work of others; Skilled in adaptability and self-motivation in staying current with CDI best practices, coding changes and clinical practices.