This position is responsible for the daily operations of the Clinical Documentation Improvement Program at AnMed Health System and affiliated facilities as directed . Must oversee the review processes and appropriate documentation requirements of complex patients in acute and chronic disease states. Must demonstrate leadership and management skills to promote effective and efficient review of physician documentation to support the patient’s level of care and appropriate assignment of DRG’s and develop action plans for improvement. Demonstrates effective communication and collaboration skills with interdisciplinary teams including, but not limited to, physicians, nurse practitioners, PA’s, and the department managers for Finance, Health Information Management (HIM), Care Coordination, and Health Informatics. The Manager creates a support structure within the medical staff for facilitating and achieving clinical and operational excellence related to documentation improvement efforts. Provides direction and supports education of all phases of the Clinical Documentation process as required and is accountable to work in a collegial manner with physicians, staff and consultants.
Qualifications: Minimum five (5) years of clinical experience required with current SC RN license with minimum of three (3) years experience with Documentation Improvement programs. Bachelors in Business, Nursing or related degree required. Minimum two (2) years management experience required. CCDS required. Excellent communication and critical thinking skills. Computer experience required. Ability to work independently and meet deadlines and schedules is required. Knowledge of care delivery documentation systems and related medical record documents. Knowledge of age-specific needs and the elements of disease processes and related procedures. Strong broad-based clinical knowledge and understanding of pathology/physiology. Working knowledge of Medicare reimbursement system, coding structures, medical necessity criteria preferred, but not required. Effective coordination and communication skills.