Employment Type:

Full time

Shift:

Description:

Remote based work location

POSITION PURPOSE

At the direction of the Regional Manager, Clinical Documentation Integrity (CDI), this position supervises daily operations of the CDI program for the Health Ministries (HMs) within their region. Provides direct oversight of the Clinical Documentation Specialist and Clinical Documentation Integrity Coordinator.

Working with the Regional Manager, Clinical Documentation Integrity, is directly responsible for the daily assessments of current Clinical Documentation Specialist staffing levels and processes. Ensures that defined goals are accomplished utilizing timely and compliant processes within the region and in concert with the Trinity Health System Office CDI program standards, policies, procedures and workflows.

Assists with policy and education development on the use of guidelines and proper

documentation requirements as it relates to reimbursement and other clinical data quality management for colleague training. Provides quality and productivity monitoring; coordinates and participates in performance improvement initiatives. Provides training and education to clinical documentation specialists (CDS) to enhance clinical and coding skill sets and optimal utilization of the 3M CDI software. Responsible for scheduling and work assignments for colleagues.

Works closely with Clinicians, Coding, Quality and Denials teams to facilitate documentation within the medical record and supports the patient’s severity of illness, risk of mortality, clinical validity and proper DRG assignment.

ESSENTIAL FUNCTIONS

Knows, understands, incorporates, and demonstrates the mission, vision, and values of the Ministry in leadership behaviors, practices, and decisions.

Directly supervises the daily operations for the CDI team who work onsite and remotely.

Communicates effectively with staff to ensure defined regional and/or system goals are met.

Maintains current knowledge of the MS-DRG system, CCs/MCCs, impact on quality, risk of mortality, severity of illness and CMI as well as ICD-10 coding systems and the guidelines related to Clinical Documentation Integrity.

Facilitates appropriate clinical documentation to ensure that the severity of illness, risk of mortality and level of services provided are accurately reflected in the health record.

Assists in overall quality, timeliness and completeness of the quality health record to ensure appropriate data, provider communication and quality outcomes. Serves as a resource for appropriate clinical documentation.

Responsible for scheduling and staffing assignments for the Clinical Documentation Specialist and Clinical Documentation Integrity Coordinator positions, facilitating management of personal time off and schedule change requests, assuring adequate staffing is in place. Monitors time and attendance system along with maintaining attendance records. Coordinates the work of external resources when used.

Along with the Clinical Documentation Integrity Coordinator, facilitates training of all new CDS hires.

Assists the Regional Manager, Clinical Documentation Integrity, in the recruitment, retention and supervision of CDI staff. Participates in the development of staff, including fostering teamwork, providing performance feedback, mentoring CDS and scheduling education. Collaborates with the Regional Manager, Clinical Documentation Integrity, on competency assessments, performance evaluations, counseling and/or conflict resolution.

Communicates with and educates physicians and all other members of the healthcare team regarding clinical documentation and monitors provider participation. Identifies learning opportunities for healthcare providers. Ensures that direct reports communicate, educate and engage with physicians and other members of the healthcare team regarding clinical documentation.

Collaborates with coding staff to assure documentation of discharge diagnoses and co-morbidities are a complete reflection of the patient’s clinical status and care. Ensures appropriate and accurate DRG assignment. Resolves all discrepancies in a courteous manner.

Demonstrates a thorough understanding of the MS-DRG system, CCs/MCCs, impact on quality and CMI as well as ICD-10 coding systems and the guidelines related to Clinical Documentation Improvement. Serves as a resource for the CDS team for any of the above.

Provides input for policy and procedure maintenance and development. Assists with the collection, aggregation and analysis of data. Collaborates in development and monitoring of performance to measure process outcomes, quality and productivity, and to ensure continual process improvements.

Ensures that direct reports remain current in coding guidelines and other regulatory directives that impact CDI performance. Ensures all compliance and regulatory standards are met.

Ensures that direct reports perform clinical validation as part of the review process and remain current on CDI strategies.

Maintains superuser level skill set in the use of 3M/360 and leverages technology and system reporting to improve CDI team efficiency and effectiveness. Monitors the CDI Dashboard and reporting to identify opportunities for improvement and areas of focus.

May perform CDI reviews to support program during high volume, short staffing periods.

Maintains a working knowledge of applicable Federal, State, and local laws and regulations, Trinity Health Corporate Integrity Program, Code of Ethics, as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical, and professional behavior.

Hourly pay range: $45.3969 - $68.0953

MINIMUM QUALIFICATIONS

Bachelor’s Degree in Health Information Management, Healthcare related field or Nursing or equivalent in experience.

Must possess one of the below:

• Current Registered Nurse (RN) License

• Registered Health Information Administrator (RHIA)

• Registered Health Information Technician (RHIT)

• Certified Coding Specialists (CCS)

• Licensure as a physician assistant (PA) or Nurse Practitioner/Advanced Practice Nurse (NP/APN) or completion of medical school

• Certified Clinical Documentation Specialists (CCDS) or Certified Documentation Improvement Professional (CDIP) preferred

Minimum of five (5) years of current hospital clinical documentation integrity program experience is required. Two (2) or more years of current experience supervising hospital clinical documentation integrity program is required.

Must have thorough knowledge of CMS regulations, coding guidelines and DRG reimbursement.

Demonstrated knowledge of state and federal Hospital Acquired Conditions (HAC) and other applicable quality indicator codes (i.e. PSI, PPI, etc.).

Demonstrated, current expertise with 3M CDI Software. Working knowledge of Epic EMR preferred.

Must possess strong analytical and critical thinking skills in order to detect and resolve problems related to clinical documentation integrity.

Demonstrated ability to effectively supervise diverse and geographically dispersed teams both onsite and remote.

Excellent interpersonal skills with ability to build collaborative working relationships with clinical staff, finance and compliance.

Must possess strong written and verbal communication skills to effectively supervise clinical documentation integrity activities and communicate with a wide-ranging audience.

Intermediate computer skills required, including working knowledge of and experience using MS Word, Excel, Outlook and PowerPoint. Must be able to spend majority of work time utilizing a computer, monitor and keyboard.

Maintains professional attitude and ability to relate well with leadership, physicians, other care providers, colleagues and patients and others within the scope of the position.

Strong understanding of the Catholic health ministry in an evolving health care delivery system and changing reimbursement market.

Personal presence that is characterized by a sense of honesty, integrity, and caring as well as the ability to inspire and to motivate others to promote the philosophy, mission, vision, goals, and values of the Ministry.

PHYSICAL AND MENTAL REQUIREMENTS AND WORKING CONDITIONS

Ability to work in a fast-paced, multi-customer environment, with conflicting needs. May warrant varied and/or extended hours, with changes in workload and priorities to keep pace with the industry and advanced strategic priorities.

Must possess the ability to comply with enterprise policies and procedures.

Must be able to spend majority of work time utilizing a computer, monitor and keyboard.

The above statements are intended to describe the general nature and level of work being performed by persons assigned to this classification. They are not to be construed as an exhaustive list of duties so assigned.

Our Commitment to Diversity and Inclusion

Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by law.

Our Commitment to Diversity and Inclusion

Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.

Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity.

EOE including disability/veteran