University of Miami

Research university in Coral Gables, FL

Director, Clinical Documentation Integrity

Clinical Support & Patient AdministrationConfirmed live in the last 24 hours

Full-timeHialeah, FL, USARemote

About the Job

Requirements

A bachelor's degree in Healthcare Administration, Health Information Management, Informatics, Nursing, Leadership, Education, or a related field is required.
A current Florida registered nurse license is required.
Maintain current certification as a Certified Documentation Specialist (CCDS), Clinical Documentation Improvement Professional (CDIP), Certified Professional Coder (CPC), or Certified Coding Specialist (CCS).
Five years of clinical experience in a hospital setting and prior clinical documentation improvement experience are required.
Thorough knowledge of ICD-9-CM, ICD-10-CM/PCS, APR DRG and MS DRG, Mortality, PSI, and HAC is required.

Responsibilities

Develop annual clinical documentation improvement work plans based on system-wide initiatives and hospital goals, and report completed activities to the CMO, CNO, CFO, and quality leaders.
Review the clinical documentation program annually to ensure compliance with state and regulatory guidelines.
Support development and enhancement of clinical documentation integrity practices, including quality monitoring, ongoing competency management for clinical documentation specialists, and identification of programmatic growth and improvement opportunities.
Provide educational support to the systemwide clinical documentation improvement team to improve the accuracy and quality of patient medical records and ensure diagnoses accurately reflect patients' clinical status and care.
Provide new-hire orientation, mentoring, and ongoing education to the clinical documentation improvement team, as well as specialty-specific education to physicians and targeted service lines.
Identify clinical documentation improvement issues and work with physicians, nurses, coding, and other healthcare team members to resolve them independently.
Assist the clinical documentation improvement team with educational needs, problem resolution, time management, and critical-thinking skills development.
Implement clinical skills activities within established clinical and preceptorship models, monitor data trends, and implement educational strategies to ensure compliance with quality standards.
Collaborate with the Professional Development Department to develop and deliver new-hire clinical documentation improvement onboarding, department-specific orientation, competencies for new specialists, and educational programs to enhance team performance.
Maintain department training materials, tools, and records.
Develop and maintain the department's web-based collaborative platforms containing education topics, facility performance outcomes, and key clinical documentation improvement areas; develop, publish, and maintain a quarterly department newsletter.
Perform quality documentation audits, including patient chart reviews and query-compliance audits, to ensure specialists and providers comply with applicable rules and regulations.
Provide mentoring and ongoing feedback to the clinical documentation improvement team.
Engage physicians and providers on clinical documentation improvement topics and attend monthly service-line meetings.
Develop and present key clinical documentation improvement topics at service-line meetings.
Monitor clinical documentation improvement performance and assess team knowledge through biannual tests.
Develop and maintain clinical documentation improvement assessment tests and create education addressing topics missed.
Educate the clinical documentation improvement team about annual regulatory updates and changes.
Collaborate with leadership and medical directors to develop and deliver specialty-specific education to physicians, departments, and specialties.
Evaluate second-level review audits to identify opportunities and develop education sessions to improve team performance and physician documentation, individually and as a group.
Represent the clinical documentation improvement team at meetings as a subject matter expert.
Coordinate with coding, quality, care management, and other departments on clinical documentation improvement initiatives to synchronize and align efforts.
Participate in performance-improvement activities related to the documentation improvement team's operational processes and organizational and departmental goals.
Develop collaborative relationships and promote teamwork with coworkers, physicians, and other departments.
Collaborate with external clinical documentation improvement consultants to identify education gaps and opportunities using external and internal reporting and chart reviews.
Incorporate protocols and standards of care into daily practice; use sound judgment, decision-making criteria, and available resources to draw conclusions and take action when teaching staff; apply evidence-based practices and approaches and solve problems creatively and flexibly.
Conduct initial and follow-up concurrent reviews of targeted admissions to identify opportunities to clarify medical-record documentation so it accurately reflects patient acuity and supports the level of care.
Coordinate with coding, health information management, care management, and other departments to ensure records reflect patient acuity and the level of care provided.
Review medical records concurrently to identify documentation not yet in the record but supported by clinical indicators.
Thoroughly review charts to identify comorbidities and complications, document them in the concurrent clinical documentation specialist worksheet, and discuss the appropriate principal diagnosis with providers.
Serve as a coach and role model and provide regular constructive and positive feedback.
Communicate knowledge and skills effectively, promptly, and openly with colleagues and others.
Manage multiple and fluctuating priorities professionally, using tact and diplomacy when communicating with providers, ancillary and nursing departments, facilities, departments, and administrative leaders.
Promote continuous improvement in workplace safety and environmental practices.
Ensure compliance with institutional policies and procedures, mandatory in-service employee health procedures, and federal, state, regulatory, and accrediting agency standards.
Maintain professional knowledge through affiliation with professional and technical organizations and participation in continuing education, conferences, seminars, and workshops.
Adhere to University and unit-level policies and procedures and safeguard University assets.

Desired Qualifications

A master's degree or graduate degree is highly preferred.
A physician who is a foreign medical graduate (MD) with extensive clinical and clinical documentation improvement experience will be considered.

Current Employees:

If you are a current Staff, Faculty or Temporary employee at the University of Miami, please click here to log in to Workday to use the internal application process. To learn how to apply for a faculty or staff position, please review this tip sheet.

The Director, Clinical Documentation Improvement is responsible for progress towards goals and objectives for the Health System’s Clinical Documentation Improvement program, in collaboration and as directed by the Clinical Documentation leadership team. Based on System-wide initiatives and hospital goals will develop annual CDI workplans and report completed activities to CMO, CNO, CFO and Quality leaders. Annually review the Clinical Documentation program to ensure compliance to state and regulatory guidelines. Participates in and actively supports development and enhancement of clinical documentation, integrity practice with emphasis on quality monitoring, management of on-going competencies for Clinical Documentation Specialists, identification of programmatic opportunities for growth and improvement. This individual provides educational support to the systemwide clinical documentation improvement team to improve accuracy and quality in patient’s medical record and to ensure that diagnoses are an accurate reflection of the patient’s clinical status and care. The Director, CDI is responsible for providing new hire orientation, mentoring, and on-going education to the CDI team, as well as to provide specialty-specific education to physicians and targeted service lines. This individual will serve as a subject matter expert in CDI and provider engagement and reports to the AVP, Clinical Care Transformation.

1.   Identify Clinical Documentation improvement issues and foster excellent communication with physicians, nurses, coding, and other members of the health care team to be able to work independently to resolve such issues.
2.   Assists CDI team with educational needs, problem resolution, time management, and critical thinking skills development.
3.   Implements clinical skills activities within established clinical and preceptorship models, monitors data trends, and implements educational strategies to ensure compliance with quality standards.
4.   Collaborates with the Professional Development Department to develop and provide new hire CDI onboarding and department specific orientation program and competencies for new CDI Specialists, as well as educational programs to address and enhance the CDI team performance.
5.   Maintains all department training materials, tools and/or records.
6.   Develops and maintains department’s web-based collaborative platforms with education topics, performance outcomes by facility and key areas for CDI. Develops and publishes and maintains quarterly department newsletter.
7.   Performs quality documentation audits, including chart review and query compliance of patient records, to ensure CDI Specialists and providers are compliant with applicable rules and regulations.
8.   Provides mentoring and ongoing feedback to the CDI Team.
9.   Engages physicians/providers on CDI topics and attends monthly service line meetings.
10.   Develops and presents key CDI topics at all service line meetings.
11.   Monitors CDI performance and tracks CDI team knowledge through bi-annual assessment tests.
12.   Develops and maintains CDI assessment tests and develops education around topics missed.
13.   Provides education to the CDI team related to the annual regulatory updates and changes.
14.   Collaborates with Leadership and Medical Directors in the development and delivery of specialty specific education to physicians, departments, and specialties.
15.   Evaluates second level review audits for areas of opportunity and develop education sessions to enhance the CDI team performance and/or physician documentation, both as a group and individually to ensure CDI success (IRR).
16.   Represents the CDI team at various meetings as a clinical documentation improvement subject matter expert.
17.   Coordinates with other departments (e.g., Coding/Quality/Care Management) regarding CDI initiatives to ensure efforts are synchronized, consistent, and effective.
18.   Participates in performance improvement activities related to the operational processes for the Documentation Improvement Team, as well as related organizational/departmental goals.
19.   Develops collaborative relationships and promotes teamwork with co-workers, physicians and other departments.
20.   Collaborates with external CDI consultants to determine any education gaps or opportunities identified via external reporting, internal reporting, chart reviews, etc.
21.   Incorporates protocols and standards of care into daily practice. Uses sound judgement, decision making criteria, and available resources for drawing conclusions and taking required action when teaching staff. Applies evidence-based practices and approaches, and solves problems using creativity and flexibility.
22.   Conducts initial and follow-up concurrent reviews on targeted admissions for opportunities to clarify documentation in the medical record for accurate reflection of the acuity of the patient and justifying the level of care.
23.   Coordinates with coding, HIM, Care Management, and other departments to achieve a record that reflects the acuity of the patient and level of care provided.
24.   Reviews medical record concurrently for documentation not yet in the record but supported by clinical indicators.
25.   Performs a thorough chart review to identify co-morbidities/complications, and documents these appropriately within the concurrent CDS worksheet. Discusses the appropriate principal diagnosis of the patient with the providers.
26.   Displays leadership and accountability, serving as coach and role model and giving regular constructive and positive feedback
27.   Communicates effectively, timely and in open and honest manner, sharing knowledge and skills with colleagues and others.
28.   Displays mental and emotional effort required to function effectively in an environment with multiple and fluctuating priorities. Demonstrates professionalism, tact and diplomacy required for communication with providers, ancillary and nursing departments, facility, department, and administrative leaders.
29.   Promotes continuous improvement of workplace safety and environmental practices.
30.   Ensures compliance with all institutional policies and procedures including mandatory in-service employee health procedures, federal, state, regulatory and accrediting agencies standards.
31.   Maintains professional knowledge by affiliating with professional and technical organizations, and participating in applicable continuing education programs, conferences, seminars, and workshops.
32.   Adheres to University and unit-level policies and procedures and safeguards University assets.
This list of duties and responsibilities is not intended to be all-inclusive and may be expanded to include other duties or responsibilities as necessary.

Education: Bachelor’s degree in Healthcare Administration, Health Information Management, Informatics, Nursing, Leadership, Education, or related field; Master’s degree is highly preferred. Graduate degree preferred; Current FL RN License; FMG (MD) with extensive clinical and CDI experience will be considered.

Must maintain current one of the following:
Certified Documentation Specialist (CCDS); Clinical Documentation Improvement Professional (CDIP).
Certified Professional Coder (CPC); Certified Coding Specialist (CCS).

Experience:
Five (5) years of clinical experience in hospital setting; prior CDI experience required.
Thorough knowledge of ICD-9-CM, ICD-10-CM/PCS, APR DRG and MS DRG, Mortality, PSI and HAC required.

The University of Miami offers competitive salaries and a comprehensive benefits package including medical, dental, tuition remission and more.

UHealth-University of Miami Health System, South Florida's only university-based health system, provides leading-edge patient care powered by the ground breaking research and medical education at the Miller School of Medicine. As an academic medical center, we are proud to serve South Florida, Latin America and the Caribbean. Our physicians represent more than 100 specialties and sub-specialties, and have more than one million patient encounters each year. Our tradition of excellence has earned worldwide recognition for outstanding teaching, research and patient care. We're the challenge you've been looking for.

The University of Miami is an Equal Opportunity Employer. Applicants and employees are protected from discrimination based on certain categories protected by Federal law.

Job Status:

Full time

Employee Type:

Staff

About the Company

University of Miami

Research university in Coral Gables, FL

The University of Miami is a private research university focused on education, discovery, and service, with undergraduate, graduate, and professional programs.

Company size: Not listed
Company stage: Not listed
Total funding: Not listed
Headquarters: Not listed
Founded: Not listed

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