Clinical Documentation Improvement Jobs in Florida

Location: Miramar, Florida

At Memorial, we are dedicated to improving the health, well-being and, most of all, quality of life for the people entrusted to our care. An unwavering commitment to our service vision is what makes the difference. It is the foundation of The Memorial Experience.

Summary

The Director of Clinical Documentation Integrity (CDI) is primarily responsible for overseeing clinical documentation integrity processes, practices, and operations for all hospitals at the Healthcare System level. Serves as the Memorial Healthcare System’s (MHS) primary subject matter expert and authoritative resource on the interpretation and application of CDI practices. This role uses clinical, coding and CDI expertise to perform daily management of the CDI program. This leader is involved in the direction and education of all phases of the CDI Specialist role, from onboarding new hires to covering new service lines.

Responsibilities

- Responsible for physician education to improve the accuracy of documentation in patient medical records.
- Participates in new resident training sponsored by GME office.
- Serves as the liaison between the medical staff and CDI staff regarding documentation and query issues and strategies.
- Assists with the planning of ad hoc CDI consultation and educational sessions requested by specific providers or service line departments.
- Provides education and consultation to physicians, mid-level providers, residents, and other clinical departments to improve the accuracy of documentation in patient medical records.
- Evaluates the adequacy and effectiveness of internal and operational controls designed to ensure CDI practices are compliant with regulatory requirements.
- Leads and implements provider documentation strategies by working closely with the Medical Director of Centralized UR-HIM, CMOs, Hospitalist Physician leaders, CFOs, Vice President - Chief Medical Information Officer (CMIO), HIM leaders, and the medical staff.
- Monitors the success of the team by analyzing and trending KPIs to include Case Mix Index (CMI) and Severity of Illness (SOI) shifts.
- Determines the needed staffing for each facility and will be responsible for budgeting accordingly.
- Directs staff training; develops and maintains a training plan for all new CDI staff members.
- Provides online CDI Boot Camp training program for new hires.
- Facilitates joint continuing education sessions of CDI and coding staff.
- Addresses ongoing CDI education needs based on audit findings and coding guideline changes.
- Directs ongoing feedback to CDI staff regarding the quantity and quality of provider documentation queries in collaboration with CDI Auditors.
- Ensures compliant query practice.
- Identifies opportunities for program improvement and collaborates with CDI Manager, CDI staff, CDI Auditors, HIM leaders and clinical leadership to advance initiatives.
- Collaborates with CDI Auditors to ensure CDI staff follows the audit response process.
- Works with coding leaders to continuously evaluate the CDI-coder reconciliation process to promote efficient workflows.
- Ensures compliant queries following AHIMA and ACDIS guidelines for CDI.
- Provides leadership to the CDI staff.
- Actively participate in MHS-wide leadership teams providing communication of CDI goals and strategies to promote ongoing improvement and integrity of provider documentation.
- Chairs and facilitates weekly CDI meetings.
- Develops CDI work plan to address documentation challenges with input from medical staff, HIM leaders, clinical leaders, and Information Technology to make changes to EMR provider workflows and provider alerts.
- Serves as liaison between medical staff and CDI staff regarding query issues and resolution.
- Provides guidance to the CDI Manager in preparing performance evaluations and applying disciplinary action.
- Approves hiring, training, education, policies, procedures, and makes budget recommendations related to CDI operations.
- Provides guidance to CDI staff on MSDRGs, APRDRGs and shifts in case-mix and severity levels for cases with documentation opportunities.
- Leads and coordinates efforts between the CDI software vendor and IT to maintain, monitor, and enhance the effectiveness of the CDI software.
- Drives optimal use of the CDI technology software and reporting capabilities.
- Utilizes and adopts the CDI operational database to provide CDI metrics to HIM, Finance, and Medical Staff leadership.
- Analyzes CDI operational reports and dashboards monthly.
- Generates, distributes, and interprets reports to executives, clinical leaders, and operational leaders.
- Reviews CDI metrics and provides data interpretation to leadership for MHS-wide quality improvement and compliance activities.

Competencies

- Business Acumen
- Concern for Quality
- Develop Relationships
- Lead Through Vision
- Manage Performance

Education And Certification Requirements

- Bachelors: Health Information Management (Required)
- Certified Coding Specialist (CCS) - American Health Information Management Association (AHIMA)
- Registered Health Information Administrator (RHIA) - American Health Information Management Association (AHIMA)
- Registered Health Information Technician (RHIT) - State of Florida (FL)
- Registered Nurse Compact License (RN LICENSE COMPACT) - Compact RN Multistate
- Registered Nurse License (RN LICENSE) - State of Florida (FL)

Additional Job Information

Complexity of Work: This role requires critical thinking skills, effective communication, decisive judgment, and the ability to build and foster positive relationships. The incumbent must be able to lead others and take appropriate action when required. Advanced clinical expertise and extensive knowledge of complex disease processes and understanding of pathology and physiology of diseases in an inpatient setting. Expertise in MSDRGs, APRDRGs, ICD10 coding, Rehab IRFPAI, and CDI practices. Proficiency with Microsoft applications, including spreadsheets and presentation software. Extensive knowledge of reporting software and EMRs. Ability to work with senior leadership, physicians and MHS staff with various levels of education and experience. Ability to collaborate and create supportive working relationships with physicians and other clinical professionals. Knowledge of project management processes. Ability to plan, organize, motivate, mentor, direct and evaluate the work of others. Skilled in adaptability and self-motivation in staying current with CDI best practices, coding changes and clinical practices.

Required Work Experience: Five (5) years of CDI management experience. Equivalent work experience may substitute for education requirement: Associate’s degree plus seven (7) years of CDI management experience. High school diploma plus nine (9) years of CDI management experience.

Other Information

Additional Education Info: or relevant field of study
Additional Credential Info: CDIP (AHIMA Certified Documentation Integrity Practitioner) or CCDS (ACDIS Certified Clinical Documentation Specialist) or CDIP credential (Certified Documentation Integrity Practitioner)

Working Conditions And Physical Requirements

- Asbestos = 0%
- Audible Speech = 60%
- Bending and Stooping = 40%
- Bio hazardous Waste = 0%
- Biological Hazards - Respiratory = 0%
- Biological Hazards - Skin or Ingestion = 0%
- Blood and/or Bodily Fluids = 0%
- Climbing = 0%
- Communicable Diseases and/or Pathogens = 0%
- Computer Monitor = 60%
- Cytotoxic Chemicals = 0%
- Depth Perception = 60%
- Distinguish Color = 60%
- Domestic Animals = 0%
- Dust = 0%
- Extreme Heat/Cold = 0%
- Fire Risk = 0%
- Gas/Vapors/Fumes = 0%
- Hazardous Chemicals = 0%
- Hazardous Medication = 0%
- Hazardous Noise = 0%
- Hearing Acuity = 60%
- Heating Devices = 0%
- Hypoxia = 0%
- Keyboard Entry = 60%
- Kneeling = 40%
- Laser/High Intensity Lights = 0%
- Latex = 0%
- Lifting or Carrying > 75 lbs Non-Patient = 0%
- Lifting or Carrying 0 - 25 lbs Non-Patient = 40%
- Lifting or Carrying 25.01 lbs - 75 lbs Non-Patient = 0%
- Lifting/Carrying Patients 35 Pounds or Greater = 0%
- Magnetic Fields = 0%
- Moving Mechanical Parts = 0%
- Needles/Sharp Objects = 0%
- Potential Electric Shock = 60%
- Potential for Physical Assault = 0%
- Pushing or Pulling > 75 lbs Non-Patient = 0%
- Pushing or Pulling 0 - 25 lbs Non-Patient = 40%
- Pushing or Pulling 26 - 75 lbs Non-Patient = 0%
- Radiation = 0%
- Reaching = 40%
- Repetitive Movement Foot/Leg = 0%
- Repetitive Movement Hand/Arm = 60%
- Running = 0%
- Seeing - Far = 60%
- Seeing - Near = 60%
- Sitting = 60%
- Smelling Acuity = 0%
- Squatting = 20%
- Standing = 60%
- Sudden Decompression During Flights = 0%
- Taste Discrimination = 0%
- Unprotected Heights = 0%
- Walking = 60%
- Wet or Slippery Surfaces = 0%

Shift

Disclaimer: This job description is not intended, nor should it be construed to be an exhaustive list of all responsibilities, skills, efforts or working conditions associated with the job. It is intended to indicate the general nature and level of work performed by employees within this classification. Wages shown on independent job boards reflect market averages, not specific to any employer. We encourage candidates to talk to their Memorial Healthcare System recruiter to discuss actual pay rates, during the hiring process.

Memorial Healthcare System is proud to be an equal opportunity employer committed to workplace diversity. Memorial Healthcare System recruits, hires and promotes qualified candidates for employment opportunities without regard to race, color, age, religion, gender, gender identity or expression, sexual orientation, national origin, veteran status, disability, genetic information, or any factor prohibited by law. We are proud to offer Veteran’s Preference to former military, reservists and military spouses (including widows and widowers). You must indicate your status on your application to take advantage of this program. Employment is subject to post offer, pre-placement assessment, including drug testing. If you need reasonable accommodation during the application process, please call 954-276-8340 (M-F, 8am-5pm) or email TalentAcquisitionCenter@mhs.net.