Inpatient Clinical Documentation Integrity Manager - FT - Days - MSS

About the role

Responsible for managing the daily operations of inpatient clinical documentation integrity consistent with administrative, medical, ethical, regulatory and governmental requirements. Oversees improvement in the overall quality, completeness and accuracy of medical record documentation to ensure patient's acuity of care and severity of illness are accurately reflected in the medical record. Provides education to physicians and other care providers on documentation guidelines.

Responsibilities

• Maintains thorough knowledge of ICD-10CM/PCS coding principles and guidelines; possesses substantial knowledge of MSDRG and APRDRG reimbursement systems and guidelines for compliant provider documentation clarification.
• Serves as an expert resource for all CDI and coding staff.
• Manages staff relations including performance management, staff satisfaction, and conflict management.
• Performs and oversees scheduling, recruitment, payroll, and updating clinical documentation integrity (CDI) policies and procedures.
• Evaluates and counsels CDI specialists' work performance, attendance, annual reviews, work schedule and paid leave requests.
• Conducts timely performance reviews within MHS required due dates.
• Orients and mentors new CDIS to MHS applications, workflow and Health Information Management (HIM) policies and procedures.
• Provides ongoing, one-on-one, or group education related to documentation integrity and compliance to physicians, extenders, nursing, clinical dieticians, wound care specialists, physical therapists and other allied health professionals as needed.
• Works closely with the Auditor, Clinical Documentation Integrity (CDI) Compliance to determine educational topics for staff training.
• Participates in MHS system-wide Quality and Patient Safety work groups to facilitate accurate and complete provider documentation.
• Oversees CDI collaboration with Quality Management and Population Health specialists to advise of Patient Safety Indicators (PSIs), Hospital Acquired Conditions (HACs) and Bundled Payments for Care Improvement (BPCI) admit diagnoses/Diagnosis Related Groups (DRGs).
• Determines work assignments, monitors employee work activities and schedules all training needs.
• Assures appropriate CDI coverage to perform initial and follow-up medical record reviews.
• Monitors staff compliance with CDI quality and productivity standards; advises employees of monthly quality and productivity results.
• Maintains strict adherence to patient confidentiality according to MHS Standards and regulatory requirements.

Qualifications

• Accredited Program (Required)
• Registered Health Information Technician (RHIT) - State of Florida (FL)

Skills

• Thorough knowledge of ICD-10CM/PCS coding principles and guidelines
• Substantial knowledge of MSDRG and APRDRG reimbursement systems and guidelines
• Expert resource for CDI and coding staff
• Effective time management and decisive judgment
• Ability to accurately determine the correct ICD-10-CM/PCS codes and MSDRG or APRDRG to hospitalized inpatients under CDI review
• Proficient in basic computer skills including Microsoft Office applications, utilizing a computerized encoder and electronic medical record system
• Ability to work well with physicians and other allied health staff
• Professional responsibility and fosters teamwork

Benefits

Additional Education Info: Graduate of an accredited school of HIM or nursing.

Additional Credential Info: Must be a Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Coding Specialist (CCS), or Registered Nurse (RN).

Pay

Compensation and benefits will be determined based on qualifications and experience.

Schedule

Shift Primarily for office workers - not eligible for shift differential