Director Clinical Documentation Integrity

About the role

Provides oversight leadership and guidance to facilitate growth and improvement of the MedStar Clinical Documentation Integrity (CDI) program to promote documentation that is in accordance with CMS and other government regulations and with appropriate clinical practice standards. Expands CDI initiatives that are integral to facilitation of optimal patient outcomes in addition to regulatory compliance and accurate reimbursement. Collaborates with CDI Physician Advisor and Medical Staff Leadership in the ongoing education efforts involving clinical documentation improvement and ethical standards for clinical providers, Coding and CDI teams. Collaborates with system wide VPMAs and Physician Advisors, Corporate Quality, Coding Operations and Quality Assurance.

Responsibilities

• Contributes to the achievement of established department goals and objectives and adheres to department policies, procedures, quality standards and safety standards; complies with governmental and accreditation regulators.
• Directs and leads day-to-day processes and manages workflow improvements, system implementation and optimization, and project management of the CDI program.
• Leads the CDI team to ensure accurate, concise and compliant provider documentation practices that reflect severity, intensity and complexity of patient care through effective policies and procedures, staff and provider training, and compliant query practices.
• Demonstrates advanced understanding of clinical concepts and coding guidelines.
• Assists with ongoing staff competencies evaluations and performance improvement plans.
• Conducts ongoing quality assessment and education of the CDI specialists.
• Provides leadership to the CDI team to support strong data with evidence-based criteria as approved by national standards and in conjunction with external payors and rating agencies such as CMS, Leapfrog, Healthgrades, US News and World Report, etc.
• Analyzes, tracks and trends CDI data and metrics to provide periodic reports (monthly, quarterly) to regional and corporate leadership.
• Participates in committees and shares results of studies, trends and activities that promote improvement in clinical and documentation practices.
• Facilitates ongoing education and training for CDI staff, medical staff including new residents that supports quality documentation practices, compliance with regulations, appropriate supporting clinical data as approved by national standards as well as external payors payment models such as AHEAD and TEAM models, rating agencies such as CMS, Vizient, Leapfrog, Healthgrades, US News and World Report and other third-party agencies.
• Holds CDI team accountable for meeting key performance outcome indicators and operational process metrics.
• Reviews and utilizes CDI software and technology to promote program excellence; works with IT or software vendors on updates or desired programmatic changes to systems.
• Collaborates with CDI Physician Advisor in leading education as needed to Physician leads to align on best practices and education around compliant and ethical means of achieving accurate and complete documentation that promotes best clinical practice in the organization.
• Coordinates development of documentation policies, clinical criteria and standard definitions (e.g., malnutrition, sepsis, etc.) and collaborates with coding and physicians to deploy.

Requirements

• Education: Bachelor's degree required; completed coding courses in ICD-10-CM/PCS required; Master's degree preferred.
• Experience: Minimum of five (5) years' experience in the acute care setting in the clinical documentation specialist role in documentation review including coding and DRG analysis required; 3–4 years Director, Manager or Supervisor level experience in CDI required; experience working with physicians and clinical professionals required. One year of relevant professional-level work experience may be substituted for one year of required education.
• Licenses and Certifications: CDIP – Clinical Documentation Improvement Professional credential from AHIMA required or CCDS – Certified Clinical Documentation Specialist credential from ACDIS required; and CCS – Certified Coding Specialist credential from AHIMA preferred or CIC – Certified Inpatient Coder from AAPC preferred or CPC – Certified Professional Coder from AAPC preferred; RN, MD, LPN, DO preferred.

Skills

• Basic computer skills including working knowledge of Word, PowerPoint, Excel and other applications.
• Excellent interpersonal skills including verbal and written communications; good public speaking and presentation skills; attention to detail; follow up on outstanding issues; ability to organize priorities and meet deadlines; ability to listen and collaborate yet stand firm in communications with physicians and other clinicians.
• Experience with Electronic Medical Records Systems and prior work with Solventum, Optum, Epic, Cerner, etc.; Clintrac, 3M 360 and Cerner a plus.
• Knowledge of Maryland rate setting and reimbursement under the CMS waiver.
• Knowledge of inpatient acute care standards for coding, The Joint Commission, HIPAA and other regulatory requirements.

Pay

Hiring range: USD $134,118.00 – USD $241,488.00 per year.