Description

JOB SUMMARY

Collects and analyzes data to provide reports for hospital wide use and to make recommendations as appropriate. Participate in the planning, development and implementation, and ongoing success of the Clinical Documentation Management Program within the company. Educates members of the patient care team regarding documentation guidelines, including attending physicians, nursing, and other interdisciplinary team members. Responsible for reviewing medical records to facilitate and obtain appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient, by improving the quality of the physicians’ clinical documentation and completeness of clinical documentation.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Include the following. Others may be assigned.

Monitoring and Building CDI team

Oversee and act as resource for Clinical Documentation Improvement departments across Conifer Health including monitoring daily activity and completion of performance and metric reports. Test, interview, hire and retain CDI staff. Lead meetings with team leads and CDI l staffImprove medical CMIOversee market CDI programs Enforces company, departmental policies, practices, procedures and work rules in accordance with approved policies and assists in the development and implementation of new policies.

Education/Development/Communication

Educates department and facility staff as needed Communicates/Completes Clinical Documentation Improvement (CDI) activities and coding issues (lacking documentation, physician queries, etc.) for appropriate follow-up and resolutionDevelop a collaborative CDI and Coding teamCDI leader for ICD 10 impact – ICD10 Core team and education leader of CDI staff

Analysis/Implementation

Performs analysis, identifies trends, validation of compliance as related to the clarity of documentation. Analysis and interpretation of regional and facility-specific data and CDI audits

Record Review:

As needed, completes initial medical records reviews of patient records within 24-48 hours of admission for a specified patient population to: (a) evaluate documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate MS-DRG assignment, risk of mortality and severity of illness; and (b) initiate a review worksheet. Conducts follow-up reviews of patients every 2-3 days to support and assign a working or final MS-DRG assignment upon patient discharge, as necessary.Formulate physician queries regarding missing, unclear or conflicting health record documentation by requesting and obtaining additional documentation within the health record, as necessary.Collaborates with case managers, nursing staff and other ancillary staff regarding interaction with physicians regarding documentation and to resolve physician queries prior to discharge.

Professional Development:

Stays current with AHA Official Coding and Reporting Guidelines, CMS and other agency directives for ICD-9-CM. Attends mandatory coding seminars on annual basis (IPPS and OPPS, ICD-9-CM and CPT updates) for inpatient. Quarterly review of AHA Coding Clinic. Attends Quarterly Coding Updates and all coding conference calls as well as any required CDI education. Other duties as assigned

SUPERVISORY RESPONSIBILITIES

If direct report positions are listed below, the following responsibilities will be performed in accordance with guidelines, policies and procedures and applicable laws. Supervisory responsibilities include interviewing, hiring, and training employees; planning, assigning and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems.

No. Direct Reports (incl. titles) CDI Lead and CDI Specialist

No. Indirect Reports (incl. titles) CDI Specialist

KNOWLEDGE, SKILLS, ABILITIES

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

CDI Subject Matter ExpertKnowledge of Medicare Part A and familiar with Medicare Part BKnowledge of disease pathophysiology and drug utilizationKnowledge of MS-DRG classification and reimbursement structuresPC/Systems literate including the Internet and MS office skills Ability to apply coding conventions, official guidelines, and Coding Clinic advice to health record documentationManagement of multiple priorities – effective time management skillsLeadership and organizational skills along with critical, deductive reasoning and problem solving skills Effective written and verbal communication skills including report writing and presentation skillsCapacity to work independently in a virtual office setting or at facility setting if required to travel for assignment.Understand and communicate documentation strategiesRecognize opportunities for documentation improvementFormulate clinically, compliant credible queries Ability to maintain an auditing and monitoring program as a means to measure query processReport writing with management reviewSkilled in performing quality assessment/analysisDetail oriented and analytical skillsPossesses the ability to motivate and maintain effective working relationships with staff and all stakeholders. Demonstrates strength in both performance management and leadership developmentManage change while minimizing interruption at an operational and service level

Conifer requires its candidates, as applicable and as permitted by law, to obtain and provide confirmation of all required vaccinations and screenings prior to the start of employment. This may include, but is not limited to, the COVID-19 vaccination, influenza vaccination, and/or any future required vaccines and screenings.

EDUCATION / EXPERIENCE

Include minimum education, technical training, and/or experience required to perform the job.

Three (3) or more years’ experience in CDIPreferred: Graduate from a Nursing program, BSN, or graduate of Health Information Management RHIT, RHIA preferred.Preferred: One (1) year supervisory experience or more

CERTIFICATES, LICENSES, REGISTRATIONS

Preferred: Active state Registered Nurse license or Certified Coding Specialist credentialPreferred: CDIP or CCDSPreferred: RN, RHIT, RHIA, and CCS

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Ability to sit for extended periods of timeMust be able to efficiently use computer keyboard and mouse to perform CDI functions assignmentsGood Visual acuity

WORK ENVIRONMENT

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

OTHER

The ideal candidate will have clinical documentation experience in an acute care facilityMust be able to travel occasionally

As a part of the Tenet and Catholic Health Initiatives family, Conifer Health brings 30 years of healthcare industry expertise to clients in more than 135 local regions nationwide. We help our clients strengthen their financial and clinical performance, serve their communities, and succeed at the business of healthcare. Conifer Health helps organizations transition from volume to value-based care, enhance the consumer and patient healthcare experience and improve quality, cost and access to healthcare. Are you ready to be part of our solutions? Welcome to the company that gives you the resources and incentives to redefine healthcare services, with a competitive benefits package and leadership to take your career to the next step!

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