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Form of workJob Description
Job Title:Clinical Documentation Improvement Manager
Location: Las Vegas, NV
Duration: Full Time
Position Summary:
Responsible for identification of Documentation Improvement opportunities related to ICD-10, UHDDS, CMS, and level of specificity; assists with day-to-day CDI administration and oversight of concurrent Query writing process. Collaborates with interdisciplinary teams including but not limited to physicians, Advance Practice Professionals, and leaders in revenue cycle, HIM, Quality Improvement, and Coding for accurate, comprehensive documentation that reflects the true clinical picture of the patient. Identifies strategies through data gathering and analysis of trends to establish recommendations for the sustained work process changes that facilitate complete and accurate Clinical Documentation. Utilizes clinical expertise and Clinical Documentation Improvement practices as well as facility specific tools for best practice and compliance with the mission/philosophy of the hospital.
Job Requirement
Education/Experience:
Option 1: Graduation from an accredited school of nursing and five (5) years of clinical nursing experience and three (3) years of Clinical Documentation Improvement experience. Two (2) years of experience in Clinical Documentation leadership.
Option 2: Physician graduate International MD with 5 years of acute care experience and 1 year of Clinical Documentation Improvement (CDI) experience. Two (2) years of experience in Clinical Documentation leadership.
Option 3: Equivalent to a Bachelor's degree in Health Information Management or Health Information Technology and four (4) years coding and abstracting medical records in an acute care hospital. Two (2) years of experience in Clinical Documentation leadership.
Licensing/Certification Requirements:
Option 1: Valid license by the State of Nevada to practice as a Registered Nurse and one of the following, Certified Clinical Documentation Specialist (CCDS), Certified Clinical Documentation Specialist-Outpatient (CCDS-O) OR Certified Document Improvement Practitioner (CDIP).
Option 2: Certification in one of the following: Certified Coding Specialist (CCS), Registered Health Information Technician (RHIT), or Registered Health Information Administrator (RHIA), issued by the American Health Information Management Association, Certified Professional Coder (CPC), Certified Coding Specialist-Physician-based (CCS-P), and one of the following: Certified Document Improvement Practitioner (CDIP), Certified Clinical Documentation Specialist (CCDS), Certified Clinical Documentation Specialist-Outpatient (CCDS-O)
Additional and/or Preferred Position Requirements
Minimum two (2) years of experience in CDI in a supervisory/management role.
Knowledge, Skills, Abilities, and Physical Requirements
Knowledge of:
Reimbursement and coding methodologies and guidelines; MS-DRGs, APR-DRGs; Severity of Illness, Risk of Mortality, Medical Necessity, Core and Quality Measures and impact of Length of Stay; HACs/PSIs; supervisory principles and practices; disease pathophysiology and drug utilization Clinical Documentation Improvement and coding; department and hospital safety practices and procedures; patient rights; infection control policies and practices; handling, storage, use and disposal of hazardous materials; department and hospital emergency response policies and procedures; age specific care practices.
Skill in:
Assigning and monitoring the work of others; evaluating quality control; process assessment, planning, implementation and evaluation; supervising and training staff; developing and monitoring budgets; developing staffing plans; data analysis; holding in complete confidence all information acquired from medical records and physicians; interpreting patient charts to determine whether care given was appropriate and properly documented; interpreting regulations and standards for others; writing reports, meeting minutes and other technical documents; analyzing statistical and other quantitative data; critical thinking; conflict management; dealing with departmental issues involving self or other employees in professional, forthright and impartial manner; applying investigative and interviewing techniques; communicating with a wide variety of people from diverse socioeconomic and ethnic backgrounds under stressful conditions; establishing and maintaining effective working relationships with all personnel contacted in the course of duties; efficient, effective and safe use of equipment. Preferred EPIC experience.
Physical Requirements and Working Conditions:
Mobility to work in a typical clinical setting, including stamina to stand and/or sit for extended periods of time, strength to examine and treat varied individuals, vision to use standard of ice equipment and read printed materials and a VDT screen, and hearing and speech to communicate effectively in both oral and written forms. Strength and agility to exert up to 100 pounds of force occasionally, and/or up to 50 pounds of force frequently to move objects.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this classification.
Location: Las Vegas, NV
Duration: Full Time
Position Summary:
Responsible for identification of Documentation Improvement opportunities related to ICD-10, UHDDS, CMS, and level of specificity; assists with day-to-day CDI administration and oversight of concurrent Query writing process. Collaborates with interdisciplinary teams including but not limited to physicians, Advance Practice Professionals, and leaders in revenue cycle, HIM, Quality Improvement, and Coding for accurate, comprehensive documentation that reflects the true clinical picture of the patient. Identifies strategies through data gathering and analysis of trends to establish recommendations for the sustained work process changes that facilitate complete and accurate Clinical Documentation. Utilizes clinical expertise and Clinical Documentation Improvement practices as well as facility specific tools for best practice and compliance with the mission/philosophy of the hospital.
Job Requirement
Education/Experience:
Option 1: Graduation from an accredited school of nursing and five (5) years of clinical nursing experience and three (3) years of Clinical Documentation Improvement experience. Two (2) years of experience in Clinical Documentation leadership.
Option 2: Physician graduate International MD with 5 years of acute care experience and 1 year of Clinical Documentation Improvement (CDI) experience. Two (2) years of experience in Clinical Documentation leadership.
Option 3: Equivalent to a Bachelor's degree in Health Information Management or Health Information Technology and four (4) years coding and abstracting medical records in an acute care hospital. Two (2) years of experience in Clinical Documentation leadership.
Licensing/Certification Requirements:
Option 1: Valid license by the State of Nevada to practice as a Registered Nurse and one of the following, Certified Clinical Documentation Specialist (CCDS), Certified Clinical Documentation Specialist-Outpatient (CCDS-O) OR Certified Document Improvement Practitioner (CDIP).
Option 2: Certification in one of the following: Certified Coding Specialist (CCS), Registered Health Information Technician (RHIT), or Registered Health Information Administrator (RHIA), issued by the American Health Information Management Association, Certified Professional Coder (CPC), Certified Coding Specialist-Physician-based (CCS-P), and one of the following: Certified Document Improvement Practitioner (CDIP), Certified Clinical Documentation Specialist (CCDS), Certified Clinical Documentation Specialist-Outpatient (CCDS-O)
Additional and/or Preferred Position Requirements
Minimum two (2) years of experience in CDI in a supervisory/management role.
Knowledge, Skills, Abilities, and Physical Requirements
Knowledge of:
Reimbursement and coding methodologies and guidelines; MS-DRGs, APR-DRGs; Severity of Illness, Risk of Mortality, Medical Necessity, Core and Quality Measures and impact of Length of Stay; HACs/PSIs; supervisory principles and practices; disease pathophysiology and drug utilization Clinical Documentation Improvement and coding; department and hospital safety practices and procedures; patient rights; infection control policies and practices; handling, storage, use and disposal of hazardous materials; department and hospital emergency response policies and procedures; age specific care practices.
Skill in:
Assigning and monitoring the work of others; evaluating quality control; process assessment, planning, implementation and evaluation; supervising and training staff; developing and monitoring budgets; developing staffing plans; data analysis; holding in complete confidence all information acquired from medical records and physicians; interpreting patient charts to determine whether care given was appropriate and properly documented; interpreting regulations and standards for others; writing reports, meeting minutes and other technical documents; analyzing statistical and other quantitative data; critical thinking; conflict management; dealing with departmental issues involving self or other employees in professional, forthright and impartial manner; applying investigative and interviewing techniques; communicating with a wide variety of people from diverse socioeconomic and ethnic backgrounds under stressful conditions; establishing and maintaining effective working relationships with all personnel contacted in the course of duties; efficient, effective and safe use of equipment. Preferred EPIC experience.
Physical Requirements and Working Conditions:
Mobility to work in a typical clinical setting, including stamina to stand and/or sit for extended periods of time, strength to examine and treat varied individuals, vision to use standard of ice equipment and read printed materials and a VDT screen, and hearing and speech to communicate effectively in both oral and written forms. Strength and agility to exert up to 100 pounds of force occasionally, and/or up to 50 pounds of force frequently to move objects.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this classification.
