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Memorial Healthcare System

Florida not-for-profit health system delivering care

Director – Clinical Documentation Integrity

Clinical Support & Patient AdministrationConfirmed live in the last 24 hours
Full-timeMiramar, FL, USANo salary listedIn-person

About the Job

Requirements

  • A bachelor's degree is required; acceptable additional education includes a bachelor's degree in Health Information Management or a clinical degree such as Nursing, MD, DO, or a foreign medical degree such as MBBS or MBBCh.
  • A minimum of five years of clinical nursing experience, or a bachelor's degree and RHIA/RHIT certification with at least five years of inpatient coding experience, or a bachelor's degree and CCS certification with at least five years of inpatient coding experience.
  • Advanced clinical expertise and extensive knowledge of complex disease processes, pathology, and physiology of diseases in an inpatient setting.
  • Expertise in MS-DRGs, APR-DRGs, ICD-10 coding, Rehab IRF-PAI, and clinical documentation integrity practices.
  • Proficiency with Microsoft applications, including spreadsheets and presentation software.
  • Extensive knowledge of reporting software and electronic medical records.
  • Ability to work with senior leadership, physicians, and staff with various levels of education and experience.
  • Ability to collaborate and create supportive working relationships with physicians and other clinical professionals.
  • Knowledge of project management processes.
  • Ability to plan, organize, motivate, mentor, direct, and evaluate the work of others.
  • Ability to stay current with clinical documentation integrity best practices, coding changes, and clinical practices.
  • A credential of Registered Nurse, RHIT, RHIA, or CCS is required.
  • Certifications listed include AHIMA Certified Documentation Integrity Practitioner (CDIP), ACDIS Certified Clinical Documentation Specialist (CCDS), or CDIP.

Responsibilities

  • Oversee clinical documentation integrity processes, practices, and operations for all hospitals at the healthcare system level, and serve as the system's primary subject matter expert on interpreting and applying clinical documentation integrity practices.
  • Use clinical, coding, and clinical documentation integrity expertise to manage the program's daily operations.
  • Direct and educate all phases of the Clinical Documentation Integrity Specialist role, from onboarding new hires to covering new service lines.
  • Evaluate the adequacy and effectiveness of internal and operational controls designed to ensure compliance with regulatory requirements.
  • Lead and implement provider documentation strategies in collaboration with medical, hospitalist, finance, health information management, and clinical leadership.
  • Monitor team performance by analyzing and trending key performance indicators, including Case Mix Index and Severity of Illness shifts.
  • Determine staffing needs for each facility and prepare the related budget.
  • Educate physicians to improve the accuracy of patient medical-record documentation.
  • Participate in new resident training sponsored by the Graduate Medical Education office.
  • Serve as liaison between medical staff and clinical documentation integrity staff regarding documentation, query issues, and strategies.
  • Plan ad hoc clinical documentation integrity consultation and education sessions requested by providers or service-line departments.
  • Provide education and consultation to physicians, mid-level providers, residents, and other clinical departments to improve patient medical-record documentation accuracy.
  • Direct staff training and maintain a training plan for new clinical documentation integrity staff.
  • Provide online clinical documentation integrity Boot Camp training for new hires.
  • Facilitate joint continuing-education sessions for clinical documentation integrity and coding staff.
  • Address ongoing education needs based on audit findings and coding guideline changes.
  • Provide clinical documentation integrity staff with ongoing feedback on the quantity and quality of provider documentation queries in collaboration with auditors, and ensure compliant query practices.
  • Identify program-improvement opportunities and collaborate with the clinical documentation integrity manager, staff, auditors, health information management leaders, and clinical leadership to advance initiatives.
  • Work with auditors to ensure staff follows the audit response process.
  • Work with coding leaders to evaluate and improve the clinical documentation integrity-coder reconciliation process and promote efficient workflows.
  • Ensure compliant queries in accordance with AHIMA and ACDIS guidelines.
  • Provide leadership to clinical documentation integrity staff and participate in system-wide leadership teams to communicate goals and strategies for improving provider documentation integrity.
  • Chair and facilitate weekly clinical documentation integrity meetings.
  • Develop a work plan to address documentation challenges with input from medical, health information management, and clinical leaders, and Information Technology, including changes to electronic medical record provider workflows and alerts.
  • Provide guidance to the clinical documentation integrity manager on performance evaluations and disciplinary actions.
  • Approve hiring, training, education, policies, and procedures, and make budget recommendations for clinical documentation integrity operations.
  • Guide staff on MS-DRGs, APR-DRGs, and case-mix and severity-level shifts for cases with documentation opportunities.
  • Coordinate with the clinical documentation integrity software vendor and Information Technology to maintain, monitor, and improve the software.
  • Promote effective use of clinical documentation integrity software and its reporting capabilities.
  • Use and adopt the clinical documentation integrity operational database to provide metrics to health information management, Finance, and medical staff leadership.
  • Analyze monthly operational reports and dashboards; generate, distribute, and interpret reports for executives, clinical leaders, and operational leaders.
  • Review metrics and interpret data for leadership supporting system-wide quality-improvement and compliance activities.

About the Company

Memorial Healthcare System

Florida not-for-profit health system delivering care

Memorial Healthcare System is a large not-for-profit health system in Florida that provides a wide range of medical services through its hospitals and affiliated facilities. It delivers patient-centered care through the Memorial Experience, focusing on personalized attention and comprehensive services, and includes a hiring process with post-offer drug testing. It stands out as one of the nation’s largest not-for-profit systems with about 17,000 employees and an emphasis on diversity, Veteran’s Preference, and a defined patient experience. Its goal is to deliver exceptional, personalized care and improve the health of patients, families, and the broader community.

Company size
5,001-10,000
Company stage
Not listed
Total funding
Not listed
Headquarters
Easton, PA
Founded
1953

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