System Director, Clinical Documentation Integrity

About the Role

The System Director, Clinical Documentation Integrity (CDI) oversees best practices in clinical documentation to accurately represent patient complexity for all outcomes. The CDI team is part of the Department of Quality and Safety, and the System Director reports to the Chief Quality Officer (CQO).

The System Director is responsible for a cohesive clinical documentation strategy across the health system to ensure an accurate reflection of severity of illness, resources, and care for quality outcomes and to maximize reimbursement. This includes all inpatient clinical entities: Academic adult population; pediatrics at Benioff Children’s Hospitals; community settings at St Mary’s and St Francis Hospitals; and ambulatory care for Medicare Advantage risk adjustment.

The Director serves as a strategic dyad partner with four Medical Directors for the respective clinical entities, setting the vision and standards through the program’s foundation of structure-process-outcomes. The System Director develops partnerships with clinical services and multi-disciplinary teams to ensure precise documentation reflects complex care management, including standard clinical definitions by service line experts templated into the EMR.

In collaboration with the Medical Directors, the Director provides guidance and interpretation of outcomes to support service line initiatives. The System Director collaborates with Health Information Management (HIM) leadership for Coding to ensure documentation maximizes DRG assignment for reimbursement and accuracy in quality outcomes.

The CDI System Director closely monitors team performance related to process and outcome metrics, provider engagement, and supports a significant ROI. The Director tracks quality outcomes such as case mix index (CMI), patient safety indicators (PSI), hospital-acquired conditions (HAC), sepsis, and mortality outcomes. As a strategic leader, the System Director serves as the subject matter expert for the organization’s True North quality goals and collaborates with other Department of Quality & Safety (DOQS) leaders as a multi-disciplinary strategic partner for process improvement opportunities across the health system.

Department Overview

Clinical Documentation Integrity (CDI) is a team within the Department of Quality & Safety that reviews provider documentation and facilitates accurate representation of patients treated across UCSF Health. Through collaborative relationships with clinical teams, CDI supports best practices in documentation improvement strategies with an emphasis on severity of illness, medical complexity, and quality in the medical record. CDI closely monitors case mix index, risk-adjusted outcomes, and mortality ratings.

Responsibilities

• Oversee best practices in clinical documentation to accurately represent patient complexity for all outcomes.
• Develop and implement a cohesive clinical documentation strategy across the health system to ensure accurate reflection of severity of illness, resources, and care for quality outcomes and reimbursement.
• Serve as a strategic dyad partner with four Medical Directors for respective clinical entities, setting vision and standards through structure-process-outcomes.
• Partner with clinical services and multi-disciplinary teams to ensure precise documentation reflects complex care management, including templating standard clinical definitions into the EMR.
• Provide guidance and interpretation of outcomes to support service line initiatives in collaboration with Medical Directors.
• Collaborate with Health Information Management (HIM) leadership for Coding to maximize DRG assignment for reimbursement and accuracy in quality outcomes.
• Monitor team performance related to process and outcome metrics, provider engagement, and ROI.
• Track quality outcomes, including case mix index (CMI), patient safety indicators (PSI), hospital-acquired conditions (HAC), sepsis, and mortality outcomes.
• Act as a strategic leader and subject matter expert for the organization’s True North quality goals.
• Collaborate with other DOQS leaders and serve as a multi-disciplinary strategic partner for process improvement opportunities across the health system.

Requirements

• Bachelor’s degree in nursing or related health care field, or equivalent combination of education and experience.
• Minimum 8 years of related experience.
• Demonstrated hospital management skills, with advanced expertise in clinical documentation and coding, database management, medical records processes, and external regulations.
• Proven understanding of conditions and diagnoses as they relate to reporting and reimbursement.
• Comprehensive knowledge of relevant regulatory requirements, as well as related legislative, accreditation, licensing, and compliance environments.
• Strong ability to organize, manage multiple priorities, meet deadlines, and assign work efficiently.

Preferred Qualifications

• Advanced degree in nursing or related health care field (e.g., MPH, MBA) or equivalent combination of education and experience.
• Active CA RN license.
• CCDS certification.
• Proven leadership, fiscal, and operational management skills, with the ability to collaborate effectively with physicians, management, staff at all levels, and external agencies.
• Advanced knowledge of relevant hardware and software, as well as specialty applications and healthcare information management systems used in clinical documentation, coding, data management, and reporting.