Internal Close Date: 04/20/2021
Requisition Number: 15492178
Position Code: 1167
Department: HIM Clinical Documentation
FTE Status: 1
Position Type: BUDGETED
Shift: Days
Salary Range: Market competitive, based on experience

Internal applicants - please refer to the job description on the Compensation Department intranet site for wage rate information.

Position Summary:
Plan, organize, and supervise the daily operation and maintenance of the Clinical Documentation Integrity (CDI) program. Provide CDI training and on-going education for CDI staff and departments requesting documentation education. Along with CDI staff, provides physician education and consultation to improve the accuracy of documentation in patient medical records. Maintain documentation and query tools in cooperation with HIM, and Department Documentation Improvement Champions. Provide guidance and supervision to all CDI staff, including CDI staff and educators. Provide reporting on CDI activities and operations as needed to HIM, medical staff departments, Finance and other identified departments/areas. Ensure adherence to Hospital and Departmental Policies and Procedures. No patient care assignment.
  • OVERSIGHT – Provide oversight of the CDI Department staff and actively participate in CDI taskforce, Department CDI, and organization-wide leadership team meetings providing communication and input regarding CDI goals and strategies while maintaining the organization’s strategic plan

  • TRAINING - Provide CDI training for all new CDI staff members. Provide on-going education for CDI staff based upon audit findings and changes in coding requirements. Facilitate joint continuing education of CDI staff and coders as needed

  • QUALITY– Oversee productivity and quality assessments for all assigned staff to monitor departmental performance. Coordinate with CDI Educator to provide on-going feedback to CDI staff regarding the quantity and quality of concurrent queries, as well as suggestions for additional queries. Address CDI staff questions regarding severity levels of specific cases along with HIM/Coding. Along with HIM, maintain mechanisms for auditing quality of CDI queries on an on-going basis and CDI reconciliation process

  • PHYSICIAN EDUCATION – Along with CDI staff, provide physician education and consultation to improve the accuracy of documentation in patient medical records. As determined, participate in new resident training sponsored by the graduate medical office, compliance training, and rotating residency program education sponsored by individual medical departments as requested. Serve as liaison between physician staff and CDI staff as needed regarding documentation and query issues/strategies. Participate in ad hoc CDI consultation/education sessions requested by specific medical departments or work-groups and/or HIM. Coordinate with CDI Champions for clinical advice related to clinical/coding interpretative differences. Communicate physician feedback obtained during concurrent query process to medical staff departments as appropriate in order to address any physician concerns or barriers

  • QUERY TOOLS – Maintain query tools with CDI staff, HIM, medical care teams, and/or provider champions. Maintain query guidelines along with HIM leadership. Conduct annual review of tool content based upon changes in ICD codes and revises or develops new tools as needed. Based upon audit results and consultation from external sources/experts, provide feedback to medical department champions regarding template development/revision which could enhance the accuracy of inpatient documentation. Work with IT to place appropriate tools and documentation references on the facility Intranet for access by provider champions, HIM coders, and auditors

  • SUPERVISION – Provide guidance to/supervision of entire CDI staff; prepare individual performance evaluations for staff and initiates disciplinary actions as necessary, in compliance with Human Resources policies and procedures. Approve departmental hiring, training, evaluation, discipline and discharge decisions as required. Monitor time sheets and schedules for all assigned personnel and complete payroll. Promote and encourage professional growth and development of personnel through attendance of workshops and seminars

  • COORDINATION – Coordinate the activities of the department internally and externally as needed through a variety of standing and ad hoc committees; meet on a routine basis, and as needed to support work cohesion and development between CDI and Coding staff

  • REPORTING – Run and analyze the CDI operational reports and CDI Dashboards on a monthly basis. Develop distribution plan for service specific CDI reports with feedback from Department Clinical Documentation Champions. Along with Director, provide and interpret CDI reports as needed in administrative or clinical forums as requested. Consult on clinical data interpretation for facility-wide CDI, quality improvement, database and compliance issues as requested

  • COMMUNICATION - Keep Director informed of activities, needs and problems

  • Education Requirements:
  • Bachelor's Degree in related discipline

  • Experience Requirements:
  • 1 year directly related experience

  • Licensure/Certification Requirements:
  • One of the following:

  • Certified Coding Specialist (CCS)

  • Licensed Registered Nurse (RN) in State of New Mexico or as allowed by reciprocal agreement by State of New Mexico

  • RHIT

  • RHIA

  • Physical Demands Requirements:
  • Sedentary Work: Exerting up to 10 pounds of force occasionally (Occasionally: activity or condition exists up to 1/3 of the time) and/or a negligible amount of force frequently (Frequently: activity or condition exists from 1/3 to 2/3 of the time) to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.

  • Licensure/Certification Requirements - Preferred:
  • Licensed Registered Nurse (RN) in State of New Mexico or as allowed by reciprocal agreement by State of New Mexico

  • Certified Coding Specialist (CCS)

  • Professional licensure as appropriate to the clinical objectives of the unit:
  • Licensed Registered Nurse (RN) in State of New Mexico or as allowed by reciprocal agreement by State of New Mexico

  • Certified Coding Specialist (CCS)

  • Working Conditions Requirements:
  • No or min hazard, physical risk, office environment