Clinical Documentation Manager - Tallahassee, United States - Texas Health Huguley Fws

Texas Health Huguley Fws Tallahassee, United States

1 week ago

Description

Job Description - Clinical Documentation Manager
Job Description
Clinical Documentation Manager

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Job Number
:

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Description
All the benefits and perks you need for you and your family:

Benefits from Day One
Paid Days Off from Day One
Student Loan Repayment Program
Mental Health Resources and Support

Our promise to you:

Joining AdventHealth is about being part of something bigger.

It's about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit.

AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that

together

we are even better.

Schedule
:

Full Time, onsite
Shift

:

Monday – Friday, 8am – 5pm
The community you'll be caring for:

Located on a lush tropical campus, our flagship hospital, 1,368-bed AdventHealth Orlando
We offer great benefits with immediate Health Insurance coverage
Career growth and advancement potential
Serves as the major tertiary facility for much of the Southeast, the Caribbean and South America
AdventHealth Orlando houses one of the largest Emergency Departments and largest cardiac catheterization labs in the country
We are already one of the busiest hospitals in the nation, providing service excellence to more than 32,000 inpatients and 125,000 outpatients each year

The role you'll contribute:

The Clinical Documentation Integrity Manager is a Registered Nurse and/or a Registered Health Information Administrator with a high level of clinical proficiency necessary for the oversight of the Clinical Documentation team which is comprised of registered nurses and clinical documentation specialists.

This role will oversee the review processes of complex patients that vary in age and have different developments in the acute and chronic disease states.

Must have proven leadership and management skills that will promote effective and efficient review of physician documentation that supports the patient's level of care and develop action plans for improvement.

Must have knowledge and job experience in management of processes, system implementations, and project management.

The Manager of Clinical Documentation works to strategically plan, organize, implement and evaluate the Compliant Documentation Management Program (CDMP) at AdventHealth.

This includes management of the case mix index (CMI), length of stay (LOS), severity of illness (SOI) and risk of mortality (ROM) in cooperation with the Director of Clinical Documentation Improvement and all other operational hospital departments.

The manager manages the Clinical Documentation Specialists (CDSs) in planning, implementing improvements, and re-evaluating processes to keep staff engaged and to assist in meeting department goals.

This role will oversee the review processes of complex patients that vary in age and have different developments in the acute and chronic disease states.

Must have knowledge and job experience in management of processes, system implementations, and project management.

The Clinical Documentation Manager will report directly to the Regional Clinical Documentation Director and will work extensively with CDI teams, physicians, Chief Medical Officers and Chief Nursing Officers of the current 6 hospitals in the North Florida Division in a matrix relationship to coordinate the efficient review and documentation capture of the underlying conditions that are supported by the physicians' secondary review of the patient record, upon request of the clinical documentation team members.

Develops, assesses, plans, implements, and evaluates procedures and processes for the system, offers continuing education, process improvement, and change management.

Is actively involved in future planning and strategic development for system CDI needs, to include policy development, program development, ongoing audits for the system level and campus level, and quality improvement efforts.

Works under general supervision and utilizes critical thinking skills.
Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all.
The value you'll bring to the team:

Maintains knowledge of all federal, state, and local documentation guidelines and communicates changes to all CDI staff; extensive knowledge of I10 and coding guidelines.

Develops, produces, and delivers training for CDI on an ongoing basis.

This includes monthly New Hire CDI training, CDI Preceptor Program, and on an as needed basis for current employees in the CDI Department.

Responsible for the hiring process for CDI departments.
Completes performance evaluations timely and is involved in employee counseling, coaching and termination per policy.
Provides orientation for new employees and ensures compliance with department policy and procedure.
Maintains high levels of employee engagement and job performance by providing recognition and opportunities for learning. Ability to appropriately handle stress and interact with others.
Audits new CDI members during their 90 day probationary period. Presents written and verbal updates to the CDI Managers and the CDI Director. Provides additional education based on results of audit and provides input for the 90 Day Evaluation.

Supports the hospitals' quality operating systems by generating and analyzing data and reports to identify opportunities for continuous growth and improvement; provides feedback to site-based teams and administrators, develops and implements action plans when appropriate.

Develops and monitors implementation of market departmental goals/objectives; oversees the performance improvement process for all acute care facilities within the Central Florida South division.

Monitors CDI computer applications and performs quarterly testing updates as needed (Iodine).
Meets regularly with the acute care site and regional based Physician Advisor designee.

Acts as a liaison between CDI leadership, staff members of the Revenue Cycle, other interdisciplinary team members at all applicable levels of leadership, and external partners.

Communicates appropriately and effectively with all involved parties.
Manages, develops and coaches the system wide CDS team, motivating and supporting others in overcoming barriers to understanding.
Accountable for CDMP success, including appropriate Case Mix Index.
Provides strategic oversight of CDMP, helps develop a collaborative team, and manages multiple priorities simultaneously.
Provides ongoing feedback to CDMP team, physicians, administration and Steering Committee from reports created from CDMPTrak.

Disseminates Compliant Documentation Management Program (CDMP) reports to CDMP team members and formulates action plans based upon Compliant Documentation Management Program results.

Tracks program successes and ongoing opportunities for improvement.
Manages the Process Flow Map and develops strategies that address resistance to the CDMP.
Performs staff evaluations, promoting longevity of program, providing feedback and conflict resolution to CDMP team.

Works in conjunction with Coding Liaison and CDI Director to provide in-services and continuing education to the CDS team, physicians, and clinical departments, providing highly complex information to audiences with a varied level of understanding of severity of illness and risk of mortality in an effort to ensure optimal reimbursement.

Serves as a subject matter expert and authoritative resource on interpretation and application of CDMP.Assumes personal responsibility for professional growth, development, and continuing education to maintain a high level of proficiency.

Serves as support for the Clinical Documentation Improvement Director providing backup as necessary.
Participates in job interviewing, assessment, and selection of new employees.

Maintains positive morale maintenance with clinical documentation improvement and contributes to and promotes departmental performance improvement initiatives and employee engagement.

Maintains confidentiality of employees', patients', and administrative and medical staff's information with no infractions and performs other duties as assigned.

Uses critical thinking and sound judgment in decision making keeping reimbursement

considerations in balance with regulatory compliance.
Develops and implements site facility work plans; collaborates with all members of the health careteam to ensure CDI success.
Maintains team members personal records, responsible for accurate time and attendance.
Works with employee relations with performance issues with team members.

Assist Director of CDI in analysis and evaluation of Facility CDI operations, finance, and implementation of recommend changes required to improve performance.

Develop and manage CDI communications with the CDI educator and CDI Clinical Documentation Specialist (CDS).
Understand CDI outcomes and operational metrics.
Operationalize use of analytics and leverage of data to affect performance improvement.
Strategically lead the CDI department and team to best practice standards.
Advocate with strong change management skills

Qualifications

The expertise and experiences you'll need to succeed:

KNOWLEDGE AND SKILLS REQUIRED:

Strong leadership skills
Strong critical thinking/problem-solving skills
Interpersonal skills that promote teamwork
Flexibility in prioritization
Ability to multitask
Ability to function in a stressful, fast-paced environment
Self-motivated and ability to work independently
Ability to motivate employees to attain program and organizational goals
Understanding of DRG assignments and metrics associated with the CDMP Program.
Understanding of coding guidelines for billing purposes

EDUCATION AND EXPERIENCE REQUIRED
:

4 or more years of Clinical Documentation Integrity Experience
Nursing Degree (RN, BS, BSN, or advanced degree) or Foreign Medical Graduate
5 or more years of acute clinical experience
Experience with Microsoft Office (Excel, PowerPoint, and Word)

EDUCATION AND EXPERIENCE PREFERRED
:

BSN, MSN
One or more years of coding experience
Knowledge of Cerner
LICENSURE, CERTIFICATION OR REGISTRATION REQUIRED

:

Current valid State of Florida or multi state license as a Registered Nurse

OR
Current active State of Florida license as a Nurse Practitioner, Physician Assistant or MD
LICENSURE,

CERTIFICATION OR REGISTRATION PREFERRED
:

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