UCSF

Public health sciences university in San Francisco

System Director - Clinical Documentation Integrity

Clinical Support & Patient AdministrationConfirmed live in the last 24 hours

Full-timeSan Francisco, CA, USA$148.7k - $390.9kIn-person

About the Job

Requirements

A bachelor's degree in nursing or a related health care field, or an equivalent combination of education and experience.
At least 8 years of related experience.
Demonstrated hospital management skills, with advanced expertise in clinical documentation and coding, database management, medical records processes, and external regulations.
A proven understanding of conditions and diagnoses as they relate to reporting and reimbursement.
Comprehensive knowledge of relevant regulatory requirements and related legislative, accreditation, licensing, and compliance environments.
Ability to organize, manage multiple priorities, meet deadlines, and assign work efficiently.

Responsibilities

Lead strategic planning for clinical documentation improvement programs across the health system and oversee new initiatives, processes, and performance improvement plans related to CDI.
Build a cohesive CDI strategy with health system partners for adult inpatient, pediatric inpatient, and ambulatory settings, coordinating with UCSF Medical Center, UCSF clinical departments, Benioff Children’s Hospital, Population Health, and Revenue Cycle leadership.
Provide leadership and direction for clinical quality improvement programs in collaboration with physician leaders of focused clinical areas.
Design and oversee technical and administrative operations for clinical documentation related to quality improvement activities; plan and coordinate staffing, fiscal, and material resources; and assist with developing and implementing programs and policies.
Direct and manage clinical documentation managers and supervisors, adhering to budgets, schedules, work plans, and performance requirements to achieve objectives.
Oversee policies, systems, processes, and staff training programs that facilitate extensive record review with physicians, advanced practice providers, health information management professionals, and nursing staff.
Cultivate relationships with physicians, clinicians, and coding professionals to introduce workflows, processes, and systems; coordinate efforts to ensure accurate and timely clinical documentation and Diagnosis Related Group coding; and resolve conflicts.
Collaborate with electronic medical record leadership to promote and support CDI in organization-wide information technology initiatives, including business intelligence and the electronic medical record.
Represent clinical documentation across the health system on interdisciplinary committees and advise senior management on topics affecting the medical center.
Provide strategic direction to support compliance with quality reporting requirements for the Centers for Medicare and Medicaid Services and the State of California.
Facilitate implementation and monitoring of reporting processes, responses, and performance improvement activities; lead quality improvement and educational activities.
Own and disseminate reports, analyses, and recommendations for changes internally and externally, and use reportable quality metrics to educate service-specific specialties and enhance documentation.
Maintain active professional contacts through local, state, national, and international associations.
Perform other duties as assigned.
Manage employee recruitment, performance evaluation and management, and staff development; build a culture that supports daily operations, interdepartmental collaboration, and timely achievement of objectives.
Encourage staff development; ensure subordinate supervisors recognize and reinforce staff efforts and improvements; and provide training and assistance on new processes, systems, and programs.
Communicate policy and procedure changes to staff.
Ensure current job descriptions and criteria-based performance evaluation standards for each department position.

Desired Qualifications

An advanced degree in nursing or a related health care field, such as an MPH or MBA, or an equivalent combination of education and experience.
A California registered nurse license.
Certified Clinical Documentation Specialist certification.
Proven leadership, fiscal, and operational management skills, with the ability to collaborate with physicians, management, staff at all levels, and external agencies.
Advanced knowledge of relevant hardware and software, specialty applications, and healthcare information management systems used in clinical documentation, coding, data management, and reporting.

Job Summary:

The System Director, Clinical Documentation Integrity (CDI) oversees best practices in clinical documentation to accurately represent patient complexity for all outcomes. The CDI team is part of the Department of Quality and Safety, the System Director reports to the Chief Quality Officer (CQO). The System Director is responsible for a cohesive clinical documentation strategy across the health system to ensure an accurate reflection of severity of illness, resources, and care for quality outcomes and to maximize reimbursement. Includes all inpatient clinical entities – Academic adult population; pediatrics - Benioff Children’s Hospitals; community setting - St Mary’s and St Francis Hospitals; and ambulatory for Medicare Advantage risk adjustment. The Director is a strategic dyad partner with four Medical Directors for the respective clinical entities - setting the vision and standards through the program’s foundation of structure-process-outcomes. The System Director develops partnerships with clinical services and multi-disciplinary teams to ensure precise documentation reflects complex care management. This includes partnering with clinical leaders for standard clinical definitions by service line experts templated into the EMR. In collaboration with the Medical Directors, the Director provides guidance and interpretation of outcomes to supports service line initiatives. The System Director collaborates with the health information management (HIM) leadership for Coding to ensure documentation maximizes DRG assignment for reimbursement and accuracy in quality outcomes. The CDI System Director closely follows team performance related to process and outcome metrics, provider engagement and supports a very significant ROI. The Director follows quality outcomes - case mix index (CMI), patient safety indicators (PSI), hospital acquired conditions (HAC), sepsis and mortality outcomes. The System Director is a strategic leader throughout the organization as the subject matter expert for the True North quality goals. The CDI System Director collaborates with other DOQS leaders and is a multi-disciplinary strategic partner for process improvement opportunities across the health system.

Department Overview:

Clinical Documentation Integrity (CDI) is a team within the Department of Quality & Safety that reviews provider documentation and facilitates accurate representation of patients treated across UCSF Health. Through collaborative relationships with clinical teams, CDI supports best practices in documentation improvement strategies with an emphasis on severity of illness, medical complexity and quality in the medical record. CDI closely follows case mix index, risk adjusted outcomes and mortality ratings.

Minimum Requirements:

Bachelor’s degree in nursing or related health care field, or equivalent combination of education and experience.
Minimum 8 years of related experience
Demonstrated hospital management skills, with advanced expertise in clinical documentation and coding, database management, medical records processes and external regulations
Proven understanding of conditions and diagnoses as they relate to reporting and reimbursement
Comprehensive knowledge of relevant regulatory requirements, as well as related legislative, accreditation, licensing and compliance environments
Strong ability to organize, manage multiple priorities, meet deadlines and assign work efficiently

Preferred Qualifications:

Advanced degree in nursing or related health care field (e.g., MPH, MBA, etc,) or equivalent combination of education and experience
RN: CA RN license
CCDS certification
Proven leadership, fiscal and operational management skills, with the ability to collaborate effectively with physicians, management and staff at all levels, and with external agencies
Advanced knowledge of relevant hardware and software, as well as the specialty applications and healthcare information management systems used in clinical documentation, coding, data management, and reporting

% of time	Essential Function (Yes/No)	Key Responsibilities (To be completed by Supervisor)
50%		Leadership and Administration
	Yes	Leads the strategic planning of clinical documentation improvement (CDI) programs across the health system. Oversees the implementation of new initiatives, processes, and performance improvement plans as they relate to CDI.
	Yes	In collaboration with health system partners, builds a cohesive CDI strategy that includes the adult inpatient, pediatrics inpatient and ambulatory settings. Critical operational and clinical partners include leadership from: UCSF Medical Center, UCSF clinical departments, Benioff Children’s Hospital, Population Health and Revenue Cycle.
	Yes	Provides leadership and direction towards the development of clinical quality improvement programs in collaboration with physician leaders of focused clinical areas.
	Yes	Designs and oversees technical and administrative operations for clinical documentation as it relates to quality improvement activities. Accountable for the overall administrative planning and coordination of the staffing, fiscal and material resources. Assists with the development and implementation of new programs and policies.
	Yes	Directs and manages clinical documentation managers and supervisors in assigned areas, adheres to budgets, schedules, work plans, and performance requirements in order to achieve broadly stated objectives.
	Yes	Oversees policies, systems, processes, and staff training programs are in place to facilitate extensive record review with physicians, APPs, health information management professionals, and nursing staff.
	Yes	Cultivates relationships with physicians, clinicians, and coding professionals to introduce new workflows, processes and systems; oversees coordinated efforts to ensure accurate and timely clinical documentation in the medical record and accurate coding of Diagnosis Related Group (DRG)s. Resolves any conflicts that arise.
	Yes	In collaboration with EMR leadership to promote and support clinical documentation improvement efforts in organization-wide information technology initiatives, including business intelligence and the electronic medical record.
30%		Quality and Performance Management
	Yes	Represents clinical documentation across the health system on interdisciplinary committees. Advises senior management on a range of topics impacting the medical center, such as clinical documentation. May lead efforts with functional peer group managers, involving matters between other divisions.
		Provides strategic direction to assist in ensuring compliance with quality reporting requirements with Centers for Medicare and Medicaid Services (CMS), and State of California.
	Yes	Facilitates implementation and monitoring the reporting processes, response, and performance improvement activities. Leads quality improvement and educational activities.
	Yes	Owns and disseminates developed reports, analysis and recommendation for changes with both internal and externally. Utilizes reportable quality metrics for education with service-specific specialties to further enhance documentation
	Yes	Maintains active professional contacts through local, state, national and international associations.
	Yes	Performs other duties as assigned.
20%		Department and Staff
		Manages employee recruitment, performance evaluation and management, and staff development. Develops a strong culture of teamwork to ensure the quality of daily operations, effective interdepartmental collaborations, and the timely achievement of objectives.
		Encourages staff development opportunities. Ensures subordinate supervisors recognize and reinforce people's efforts and improvements. Provides for adequate training and assistance on new processes, systems and programs.
		Communicates policy and procedure changes to staff.
		Ensures current job descriptions and criteria-based performance evaluation standards for each position in the department.
100%		(To update total %, enter the amount of time in whole numbers (without the % symbol - e.g., 15, 20) then highlight the total sum (e.g., 1%) at the bottom of the column and press F9. The total sum should add up to 100%.)

Budgeted Job Salary Range: 148,700 - 390,900

About the Company

UCSF

Public health sciences university in San Francisco

UC San Francisco is a public research university in San Francisco focused solely on health sciences, combining professional education with biomedical research and patient care. Its schools of dentistry, medicine, nursing and pharmacy train clinicians and scientists, while teams investigate cancer, immunology, genomics and neuroscience. UCSF Medical Center and Benioff Children's Hospitals connect clinical care with faculty research and training, and university clinics serve patients across Northern California. Founded in 1864, UCSF is the University of California campus dedicated to graduate and professional education and biomedical research, based in San Francisco.

Company size: 10,001+
Company stage: Not listed
Total funding: Not listed
Headquarters: Not listed
Founded: 1864

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