The Director, Clinical Documentation Improvement (CDI) is responsible for providing departmental strategic planning aligned with the corporate strategy and execution of that plan. The incumbent leads and oversees the work product of this department; offers expertise through communication and training; and provides data analysis and a variety of reports deemed relevant to both business and clinical sectors. This director is responsible for keeping the CDI department policies/procedures and processes up-to-date with industry standards; to stay current with relevant changing industry elements, such as ICD 10; and actively contribute to quality improvement initiatives related to physician documentation and coding/billing processes.
The CDI Director will be responsible to ensure the CDI team has the tools necessary to be successful in their daily concurrent record review, which includes technical support through advanced clinical documentation software selection, implementation, and use. The Director will assist in month-end client reporting and analyses to track performance and trends, as well as escalate problematic issues, as necessary. The CDI Director will work collaboratively with facility and system-level departments as cross-departmental issues arise. Improvement efforts will include up-stream and down-stream impacts and collaboration with all stakeholders.
- Responsible for CDI program to initiate, influence, direct and oversee the clinical documentation improvement program activities to include productivity, quality, education and training, auditing, report management, performance improvement initiatives, and developing standardized practices, processes, policies and procedures.
- Accountable for the capture of appropriate clinical documentation for optimal quality and financial impacts for the acute care settings.
- Leads by example and promotes teamwork through a transparent, collaborative work environment.
- Cultivates positive, professional interdepartmental relationships with HIM director, coding team, case management, quality, and medical staff to support initiatives that advance business objectives.
- Collaborates with physicians and clinical leaders as an internal expert consultant to identify and implement improvements and standardization of documentation throughout CHRISTUS Health.
- Advocate for and facilitate the best practice model for CDI; linking the capture of documented bedside care to the most accurate administrative data reporting codes and acuity capture.
- Monitors the performance of each CDI program to ensure alignment and support of department and organization initiatives.
- Provides complete, accurate, and timely reporting of clinical documentation data metrics to leadership.
- Maintain staff knowledge and understanding in the ever-changing arenas of coding guidelines, DRG groups, case management/utilization review functions, clinical documentation trends, TJC standards, core measure guidelines, and clinical quality of care issues.
- Maintain a clear working knowledge of the CDI application regarding data entry, report generation, and tracking methods.
- Clearly communicate program updates, risks, or needs in a timely manner to the Vice President, Clinical/Business Operations Transformation and actively works to resolve and mitigate risk.
- Manages the recruiting, hiring, and evaluation process of CDI staff.
- Ability to identify and articulate project obstacles/ issues and determine potential solutions while working collaboratively.
- Expresses self in a confident manner in individual and group settings
- Assist with system-wide, regional and/or facility education programs, including presentations, program development, updated materials, and promotion of these programs.
- Serves as system functional lead related to ICD-10 transition for Clinical Documentation Improvement (CDI) Program.
- Participates in other projects and duties as requested.
- BSN with R.N. license, Master's preferred.
B. Knowledge, Skills & Abilities:
- Ability to work independently and as a member of a team utilizing critical thinking skills.
- Demonstrated competence in data analysis and data interpretation.
- Knowledge of both ICD-9 and ICD-10.
- Ability to prioritize workflow and manage various initiatives.
- Demonstrated quality improvement knowledge/skills with regard to workflow and productivity processes.
- Strong speaking and writing skills required.
- Excellent presentation skills required.
- Able to produce reports in Microsoft Office components, Word, Power Point, Excel, and Access data base.
- Demonstrated effective facilitation skills.
- Good listening skills.
- Strong interpersonal communication skills with the ability to relate to all levels of education and organization positions.
C. Work Experience:
- Must have a minimum of 3-5 years progressive CDI work experience.
- 3 years prior management experience.
- Knowledgeable of ICD-10 concepts and codes.
- 3 to 5 years clinical experience in acute care setting.
- Demonstrated effective, collegial communication with physicians and business office staff through direct discussion and written communications.
D. Licenses, Registrations or Certifications: