Director, Clinical Documentation Improvement (CDI)

Director, Clinical Documentation Improvement (CDI)

BayShore, NY

Exp 7-10  

Deg Bachelors

Occasional Travel

Job Description

As the Director of Clinical Documentation Improvement you will direct the activities of the Clinical Documentation Improvement (CDI) department, facilitate modifications to clinical documentation to ensure accurate depiction of the level of clinical services and patient severity through extensive concurrent interaction with physicians, nursing staff and other caregivers, case management and medical records coding staff.

Responsibilities include:

•Ensures clinical documentation, including modifications, accurately reflect the level of service rendered and severity of illness (in compliance with government and other regulations) for all patients. ◦Oversees a system to identify admissions with specific diagnosis / DRG classifications or other categories of admissions.

◦Ensures chart review within 48-72 hours of admission to meet criteria.

◦Ensures periodic documentation review with cases that have a length of stay greater than 3 days.

•Ensures follow up reviews of clinical documentation are conducted by CDS staff to evaluate whether issues discussed and clarified with the physician have been recorded in the patient's chart.

•Ensures recommendation of possible refinement of principal diagnosis based on Clinical data on admission and concurrently during the hospital stay to facilitate appropriate DRG assignment.

•Interacts with physician regarding documentation appropriate to diagnosis and support appropriate levels of severity of illness and risk of mortality.

•Monitors tracking response to CDI and trending completion of DRG worksheets via reports generated by Clinical Documentation Specialists (CDS).

•Serves as a resource to Physicians / Case Managers and other key professional staff in matters relating to published DRG information.

•Works with medical records, finance and physician groups to develop systems to facilitate complete documentation for data reporting purposes.

•Develops and monitors strategic operating goals, objectives and budget; and reports operational performance, justification and/or corrective action.

•Develops and manages direct reports; and oversees the development and management of indirect reports.

•Builds and maintains productive inter/intra departmental and vendor work relationships to optimize operations.

•Oversees compliance with government and agency regulations

Qualifications:

•Bachelor's Degree in Nursing or related field, required. Masters Degree, preferred.

•Current license to practice as a Registered Professional Nurse in New York State.

•Minimum of seven (7) years of progressive experience in an acute care setting. Previous experience in chart review, required. Regulatory background and DRG reimbursement knowledge, preferred.

•Ability to communicate effectively with physicians and other clinical professional staff.