Clinical Documentation Jobs (NOW HIRING)

The manager of CDI is responsible for managing, coordinating and facilitating activities for the quality and completeness of clinical documentation.  Manages CDI staff and concurrent review activity at the facility level, including performing record reviews on admissions and documents findings.  Facilitates compliant modifications to clinical documentation to accurately reflect patient severity of illness, risk of mortality through extensive interaction with physicians, Case Management, other patient care givers and HIM/Coding staff.   Serves a CDI resource. Facilitates accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes.  Monitors and evaluates effectiveness of concurrent chart review and query outcomes at designated intervals. Reports CDI data to hospital departments and committees at designated intervals as assigned. Maintains accurate records to comply with departmental and regulatory agency guidelines.  Understands and complies with policies and procedures related to confidentiality of medical records. Directs and assists departmental team members with assigned responsibilities as needed. Facilitate communication and teambuilding.  Identifies opportunities for intradepartmental and interdepartmental operational improvements. Coordinates and collaborates for CDI policies/procedures/ guidelines as well as process development, implementation and re-evaluation. Supports CDI Physician Advisors at the facility level, including CDI education efforts for the medical staff.  Participation and management of special CDI projects as assigned.  Plans, facilitates and participates in staff development, departmental activities and in-service opportunities. Demonstrates actions consistent with FMOLHS code of conduct. 

1. Seven years clinical nursing experience or strong inpatient coding background with at least Seven years acute inpatient coding experience. Previous management or supervisory experience and firm understanding of CDI initiatives.
2. Graduate of accredited school of nursing with current Louisiana Nursing license or HIM degree (RHIA/RHIT) with CCS certification.
3. Knowledge of care delivery documentation systems and related medical record documents. Strong broad ?based clinical knowledge and understanding of pathology/physiology of disease processes. Excellent written and verbal communication skills, critical thinking skills and interpersonal skills to build effective partnering relationships with physicians, coding staff, and multidisciplinary hospital staff.
4. RHIT, RHIA with CCS, or RN, CCDS and/or CCS preferred.

1. Interviews, selects, trains staff in a manner that ensures efficient Documentation Improvement Program operations and complies with the relevant regulations governing the employment process.
   1. Responsible for CDI staff interviewing, hiring and performance evaluations
   2. Provide ongoing performance feedback to employees, and take corrective action when necessary. Portions of the CDS performance evaluations may be delegated to appropriate CDI coordinator when applicable
   3. When indicated, document, plan and initiate team member corrective action and counseling in fair and consistent manner, following facility policies
   4. Coordinate CDI staff orientation and training, CDI education , staff development, departmental activities and in-service opportunities
   5. Plan and conduct regular staff meetings
2. Performance Improvement and Quality
   1. Maintains appropriate controls to ensure compliance with Federal/State regulations and organizational policies to include HIPAA, Privacy, Safe Environment. Serves as the liaison with governmental agencies, FMOLHS Compliance and facility leadership.
   2. Works closely with physicians and other healthcare providers to ensure that documentation is accurate, compliant and specific. Trends data and makes operational changes for improvement in compliance with the practice quality improvement initiatives. Reports data timely and accurately.
   3. Promotes the quality and efficiency of his/her own performance by remaining current with the latest trends in field of expertise through participation in job-relevant seminars and workshops, attendance at professional conferences, and affiliations with national and state professional organizations.
   4. Produces requested or routine reports and provides appropriate feedback to physicians, administration, managers, etc., in a timely manner. Maintains an organized work environment; promotes organization and cleanliness throughout area of supervision.
   5. Facilitate query compliance and resolution processes, including escalation
   6. Monitor and evaluate effectiveness of concurrent chart review and query outcomes at designated intervals
   7. Serve as a resource for team members and physicians to help link coding guidelines and medical terminology to improve accuracy of final code assignment
3. Program Management and Daily Operations
   1. Manage and coordinate CDI operations at the facility and regional level. Demonstrate ability to plan, initiate and coordinate departmental operations
   2. Maintain appropriate lines of communication ,related to aspects of CDI operations
   3. Management of daily concurrent review activity, monitoring productivity, staffing and assignments
   4. Manage, facilitate and delegate to appropriate CDI Coordinator as indicated
   5. Works with senior management team, consultants and executives on CDI projects and in meetings. Reports CDI data outcomes to hospital departments and committees
   6. SupportsCDI Physician Advisors at the facility level, including CDI education efforts for the medical staff
   7. Work in collaborative fashion with coders, CDSs, CDI physician advisors, consultants and management staff
   8. Assists and facilitate audit process, including performing chart reviews and data analysis