Responsibilities POSITION SUMMARY : The leader of Clinical Documentation Improvement (CDI) is responsible for managing and directing the consolidated Clinical Documentation Improvement Program for STHS.
The leader is responsible for implementing policies and procedures to effectively and efficiently achieve set metrics, targets, and methods / opportunities for expanding system utilization.
Lead CDI also ensures an effective physician communication process for improving the overall quality and completeness of clinical documentation.
Promotes a partnership between the concurrent clinical reviewers, medical record coders, and physicians to improve documentation and reimbursement for STHS.
Supports the accuracy and completeness of the clinical information used for measuring and reporting physician and hospital outcomes to reflect the patient’s true severity of illness, intensity of care, and risk of mortality.
Educates all members of the health care team on an ongoing basis. This position will also assist Coding Management with reports and coding needs.
Qualifications QUALIFICATIONS : 1. Excellent written and verbal communication skills required. 2. Excellent critical thinking skills required and must be detail oriented.
3. Knowledge of age-specific needs and elements of disease process and related procedures required. Strong broad based clinical knowledge and understanding of pathology / physiology of disease processes.
4. Ability to work independently in a time-oriented environment is essential. 5. Working knowledge of Medicare reimbursement system and coding structures preferred, by not required.
6. Computer literacy essential. Must demonstrate commitment and adherence to STHS’s Compliance Program and Code of Conduct through compliance with all policies and procedures, the Code of Conduct, attendance at required training and immediately reporting suspected compliance issue(s) to the Compliance Officer.
EDUCATION / LICENSURE : 1. Bachelor degree in a healthcare field (RN / BSN). International MD degree acceptable. 2. Minimum of 5 years recent clinical / medical experience in an acute care setting or patient care setting.
3. 2 to 3 years experience with clinical documentation. Certification in Clinical Documentation Improvement a plus. 4. Must be able to travel between facilities as needed.