Department: HIM Clinical Documentation
FTE: 1.00
Full Time
Shift: Days

Position Summary:
Under limited supervision, serve as the Lead Clinical Documentation Specialist (CDIS) for the Clinical Documentation Improvement (CDI) program. Overseeing the growth and maintenance of the program throughout UNM Inpatient Hospitals. Provide leadership of the CDI staff and healthcare provider department champions. Provide CDI training and on-going education for CDI staff and departments requesting documentation education. Provide leadership of the concurrent and retroactive query process. Along with CDI staff, provides physician education and consultation to improve the accuracy of documentation in patient medical records. Maintain documentation and query tools in cooperation with HIM, and Department Documentation Improvement Champions. Provide guidance and supervision to entire CDI staff, including Coder III, RN CDI staff, and coding and documentation educators. Oversee the CDI operational database and provide CDI reports as needed to HIM, medical staff departments, and the Finance Department. Ensure adherence to Hospital and Departmental Policies and Procedures. No patient care assignment.

Detailed responsibilities:
* LEADERSHIP – Provide leadership of the CDI Department staff and facilities CDI taskforce and Department CDI meetings. Actively participate in organization-wide leadership teams providing communication and input regarding CDI goals and strategies while maintaining the organization’s strategic plan
* TRAINING - Provide CDI training for all new CDI staff members. Provide on-going education for CDI staff based upon audit findings and changes in coding requirements. Facilitate joint continuing education of CDI staff and coders as needed
* QUERY - Provide on-going feedback to CDI staff regarding the quantity and quality of concurrent queries. Provide suggestions as to opportunities for additional queries. Address CDI staff questions regarding severity levels of specific cases along with HIM/Coding. Along with HIM, maintain mechanisms for auditing quality of CDI queries on an on-going basis and CDI reconciliation process
* PHYSICIAN EDUCATION - Along with CDI staff, provide physician education and consultation to improve the accuracy of documentation in patient medical records. Participate in new resident training sponsored by the graduate medical office, compliance training, and rotating residency program education sponsored by individual medical departments as requested. Serve as liaison between physician staff and CDI staff as needed regarding documentation and query issues/strategies. Participate in ad hoc CDI consultation/education sessions requested by specific medical departments or work-groups and/or HIM
* COORDINATES - Develop work-plans for retrospective query audits with HIM (with input from medical staff departments). Provide leadership to the retrospective query process to HIM Coding management. Coordinate with CDI Champions for clinical advice related to clinical/coding interpretative differences. Communicate physician feedback obtained during concurrent and retrospective query process to medical staff departments as appropriate in order to address any physician concerns or barriers
* QUERY TOOLS - Maintain query tools with CDI staff, HIM, medical care teams, and/or provider champions. Maintain query guidelines along with HIM leadership. Conduct annual review of tool content based upon changes in ICD codes and revises or develops new tools as needed. Based upon audit results and consultation from external sources/experts, provide feedback to medical department champions regarding template development/revision which could enhance the accuracy of inpatient documentation. Work with IT to place appropriate tools and documentation references on the facility Intranet for access by provider champions, HIM coders, and auditors
* GUIDANCE - Provide guidance to/supervision of entire CDI and Coder III staff. Meet monthly and on an as needed basis with CDI and Coding staff in order to support work performance and promote group cohesion/development
* SUPERVISION - Prepare individual performance evaluations for staff and initiates disciplinary actions as necessary, in compliance with Human Resources policies and procedures. Approve departmental hiring, training, evaluation, discipline and discharge decisions as required. Promote and encourage professional growth and development of personnel through attendance or workshops and seminars
* COORDINATION - Work with IT and HIM Decision Support Analyst to maintain, improve and utilize the CDI operational database
* REPORTING - Run and analyze the CDI operational reports and CDI Dashboards on a monthly basis. Develop distribution plan for service specific CDI reports with feedback from Department Clinical Documentation Champions. Along with HIM Executive Director, provide and interpret CDI reports as needed in administrative or clinical forums as requested
* BUDGET - Along with Department Executive Director, prepare budget for CDI department annually
* DATA INTERPRETATION - Consult on clinical data interpretation for facility-wide CDI, quality improvement, database and compliance issues as requested
* OTHER DUTIES - Perform other duties as requested/required

Qualifications

Education:
Essential:
* Bachelor's Degree
Education specialization:
Essential:
* Related Discipline

Experience:
Essential:


Nonessential:
1 year directly related experience

Credentials:
Essential:
* CCS or RN or RHIT or RHIA
Nonessential:
* Certified Coding Specialist
* RN in NM or as allowed by reciprocal agreement by NM

Physical Conditions:
Sedentary Work: Exerting up to 10 pounds of force occasionally (Occasionally: activity or condition exists up to 1/3 of the time) and/or a negligible amount of force frequently (Frequently: activity or condition exists from 1/3 to 2/3 of the time) to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.

Working conditions:
Essential:
* No or min hazard, physical risk, office environment
* Subject to an annual contract and performance appraisal

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