Clinical Document Improvement Coordinator

Integral part of achieving the objectives of United Regional’s Compliance Program.  

Monitors Optum 360 for updates, ensuring appropriate work distribution, running and monitoring reports, and coordinating educational update compliance of the CDMP Team members. 

Reports to Medical Records Manager

High school diploma or equivalent required 

RHIT with two years CDI experience, RHIA, Associates Degree in Nursing or Bachelors in Allied Health Field required

2 years CDI experience, CDIP certification, CCDS certification or BSN preferred

Nursing degreed candidates must be registered with the Board of Nursing for the State of Texas.

Knowledge of Epic and Optum360 is preferred

Strong analytical/problem-solving skills, ability to integrate knowledge with job situations.

Excellent oral/written communication skills. Ability to strongly communicate and interact with all levels of professionals, including but not limited to physicians and nursing personnel, managers, various support staff departments, physician offices, in a non-confrontational manner. Must be able to communicate complex regulatory and clinical information in understandable terms.

Excellent interpersonal skills.  Must be able to communicate effectively with various System audiences.

Understands and applies the principles of customer service, service recovery.

Strong knowledge of billing/coding, healthcare reimbursement.

Strong organizational and planning skills.

Personal computer skills with emphasis on Microsoft Word, Excel and Access database program.

Demonstrates an ability to be flexible, organized and function under stressful situations.

Day to day oversight of the CDI Program to include developing a collaborative CDI Team, promoted longevity of the CDI Program, and maintain active within the organization.

Educates and mentors new employees through the on-boarding process.

Verifies and approves Kronos for staff.

Trains CDI staff on initial CDI process, concept training and on-going education related to new topics in CDI, coding and reimbursement.

Supports CDI Department with instruction relating to new technology and technology updates.

Monitors CDI compliance through quality audits and data analysis.

Provides feedback to CDI management team and staff regarding ICD 10 CM/PCS coding, DRG assignment and related Clinical Documentation issues or concerns.

Assists in development and maintenance of CDI policies and guidelines

Educates groups and individuals within and external to CDI regarding documentation, coding, DRG, ICD code assignment, and the reimbursement process.

Interacts with and educates physicians and mid-level providers individually and in groups.

Works closely with and maintains positive open communication with Corporate Compliance Officer, Medical Records Director, Physicians, Medical Record Coders, Case Managers, and Nursing Staff to accomplish the objectives of the CDI Program.

Assists with CDI Specialist responsibilities as workload permits.

Supports CDI program initiatives.

Promotes good morale and cooperation - encourages others, values their input, shares information and seeks ways to add value both to the customer and to the team.

Anticipates and responds to changing skills requirements.

Seeks opportunities to learn new skills and actively coaches and encourages team members to do the same.

Successfully integrates new hires into the CDI process to promote their development and engages in continuous development of all staff to meet changing requirements in health care documentation.

Create and disseminate CDI Reports, formulate action plans and strategies based on report results.

Complete and deliver Clinical Documentation Specialist Staff evaluations.

Develop strategies that address resistance to the program and the program tools.

Track program successes and ongoing opportunities.

Educates all internal customers on compliant documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies.

Attends and participates in multiple cross-departmental meetings where CDI is a contributor in understanding the clinical picture and appropriate DRG assignment.

Remains accessible as a subject matter expert regarding documentation, reimbursement and data interpretation as it relates to inpatient records. Conducts the quality review of inpatient CDI cases, queries, assigned codes and working DRG. Participates in process improvement activities based on audit results and hospital or institute performance improvement projects impacted by documentation.