Program Director, CDI Education
CHRISTUS System Office
CHRISTUS Health Corp Services-68700
919 Hidden Ridge Dr.
Irving, TX 75038
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Program Director, Clinical Documentation Integrity Education leads enterprise-wide education and training efforts for CDI staff, medical providers and ancillary staff on effective, compliant clinical documentation and processes. This role leads a team of CDI educators and leaders to facilitate consistent, accurate, optimal documentation by providing both formal and informal educational programs. The Program Director leads the development, implementation, and coordination of a system-wide formal CDI orientation program, including competency standards. The incumbent will work with the analytic team, leadership, and the coding department to assess documentation gaps and formulate appropriate education tools to include, but not limited to, power point presentations, memos, and documentation tips sheets that enhance knowledge and result in appropriate documentation capture of patient condition, complications, and comorbidities.
The Program Director will lead the application of teaching/learning principles in establishing an overall educational program in collaboration with CDI staff, physicians and the health care team. This position will lead regional educators to provide education for all members of the patient care team on issues relating to clinical documentation. In addition, this position will serve as resource to the CDI team, Coding Integrity, Clinical Appeals Team, Compliance, and clinical providers on optimal clinical documentation.
- Provide direction to develop, implement, and maintain formal and informal educational programs, including creating the CDI orientation programs, documentation improvement opportunities, coding and reimbursement issues, as well as performance improvement methodologies for internal customers and physicians. Analyzes and compiles accurate and complete data for statistical reporting and educational presentations, as needed.
- Directs communication and interaction with physicians and clinical staff via informal verbal communication, the use of written communication tools, and formal educational presentations. Utilizes research, analytic data and observations to provide recommendations to improve the overall quality and completeness of clinical documentation.
- Directs analysis, summarizes and documents outcomes of improvement processes for re-evaluation of ongoing program revisions. Participates as a member of work groups related to clinical documentation integrity.
- Establishes cooperative and multidisciplinary relationships with physicians, coding staff and other health team members. Acts as a resource to the CDI departments and health team members related to optimal documentation, educational needs and successful problem resolution.
- Familiarity with MS-DRG/APR-DRG's and Inpatient Prospective Payment System (IPPS), including new CMS guidelines of key elements including clinical documentation of what constitutes an inpatient admission. Along with familiarity and the ability to effectively communicate the use various coding systems and Official Coding Guidelines.
- Directs and facilitates modifications to support clinical documentation of health team members to ensure that appropriate reimbursement is received for the level of service rendered to all patients.
- Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes. Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient's chart.
- Participates in the design and directs the implementation, control and maintenance of all HIM/CDI technological systems for the effective and efficient operation of the departments and health system.
- Monitors local, national, and international trends in documentation integrity standards and implements educational changes as applicable.
- Monitors changes in legislation and accreditation standards that affect health information management and implements department changes as applicable.
- Serves as CHRISTUS Health knowledge expert on CDI issues including accuracy, clarity, consistency and compliance of health record documentation.
- Builds and maintains strategic working relationships with Medical Staff leadership (working through specific issues, committee meetings, monthly updates, etc.).
- Define, implement, and monitor strategies for improving clinical documentation resulting in quality of care, optimal case mix index, overall consistency of clinical documentation and coded data.
- In conjunction, with other department leaders the program director of CDI education will lead the effort to ensure that accurate DRG-based reimbursement for CHRISTUS Health system is achieved and claim denials are reduced, by ensuring documentation integrity.
- Promotes accurate concurrent documentation from all disciplines (physicians, nurses, dietitians, wound care specialists, physical therapy, respiratory therapy, etc.) to capture best practice documentation for specific diagnoses.
- Demonstrates knowledge of DRG payer issues for documentation opportunities, clinical documentation requirements, coding standards as applied to medical record documentation and compliance requirements. Demonstrates working knowledge of MS and APR DRG's.
- Develops and maintains a close working relationship with physicians, coders, revenue cycle team, nursing staff, health information management, quality and managed care staff, as well as other ancillary departments responsible for clinical documentation.
- Demonstrates enhanced knowledge of anatomy and pathophysiology to facilitate the increased need for granularity and specificity within the clinical documentation with the transition to new coding systems. Demonstrates the ability to accurately utilize and provide instruction related to coding guidelines, software systems and resource material.
- Improves the overall quality and completeness of clinical documentation through the application of evidence-based knowledge, analysis, in-depth review, interpretation, identification of opportunities, communication and consistent follow-up and evaluation of concurrent and retrospective (as required) medical record documentation. Interacts primarily with, but not limited to, physicians, nursing staff, other patient caregivers and health information coding staff to capture appropriate reimbursement and clinical severity for the level of service rendered to all patients, with a focus on DRG-based payers.
- Works with Clinical Data Analyst to quantify complete and accurate clinical documentation and utilization, focusing on DRG payers.
- Self-directed, independent decision-making, analytical teaching and articulate communication skills, both verbal and written.
- Bachelor's degree in Nursing required, Masters preferred.
- 3-5 years' experience in an acute hospital setting.
- 3-5 years' experience as a clinical documentation specialist
- 2-5 years' experience in formulating and presenting for education to physicians and clinical staff
- Experienced education leader with a strong understanding of the requirements for clinical coding and billing according to the rules of Medicare, Medicaid, and commercial payers preferred.
- Current RN license according to state and federal requirements if applicable.
- Certified Clinical Documentation Specialist (CCDS) issued by the Association of Clinical Documentation Improvement Specialists (ACDIS) or Certified Documentation Improvement Practitioner (CDIP) issued by The American Health Information Management Association (AHIMA).
- ICD training certification.