Manager - Clinical Documentation Integrity
Atrium Health
- Charlotte, NC
- Permanent
- Full-time
- Position manages and develops interprofessional teams, providing leadership and strategic direction for multiple value-based initiatives, including clinical documentation integrity, pre-visit planning, project management, educational programs, and data collection and analysis.
- Helps develop critical workflows and is responsible for reporting and monitoring key performance measurement activities.
- Upholds all AAH leadership behaviors while performing program oversight.
- Oversees Clinical Documentation Integrity (CDI) program; monitors and maintains the timeliness of workflow, productivity, and quality of the site CDI program; develops and monitors implementation of site departmental goals/objectives and supports the performance improvement process in conjunction with the Clinical Documentation Director.
- Aligns department with system strategy, vision, mission, and goals.
- Ensures competency of Clinical Documentation Specialist staff by conducting on-going reviews and skills assessments; provides action plans and timely constructive feedback, as needed, to enhance staff development; leads hiring, training, and performance management processes for all site-based CDI employees; coaches, mentors and empowers employees to complete tasks by providing information and support.
- Performs audits to ensure that the assigned MS-DRG that most accurately reflects the severity of illness of the patient based upon the clinical evidence documented in the record. Reviews clarifications for compliance and assignment of proper impacts. Tracks and trends program compliance to ensure adherence to all CMS regulations regarding DRG assignment.
- Supports the CDI program by generating and analyzing reports and data to identify opportunities for continuous growth and improvement; provides feedback to individual staff and other facility-based leadership. Develops and implements action plans when appropriate.
- Monitors CDI computer applications and assists IAS with quarterly updates and testing as appropriate.
- Demonstrates knowledge and understanding of severity based DRG systems; All-Patient Refined and Medicare Severity (APR-DRG), Medical Severity Diagnostic Related Group System (MS-DRG) and Hierarchical Condition Categories (HCC).
- Interacts with the physician advisor, attending physicians, and/or other designated members of the healthcare team when applicable and follow-up is warranted per escalation guideline.
- Works with other departments such as coding, corporate compliance, quality, and finance to support Corporate Goals.
- Participates in the ongoing education of providers and other healthcare team members to identify medical record documentation improvement opportunities employing conflict resolution skills, as necessary.
- Ensures that all written requests to physicians for additional documentation support Corporate Compliance policies.
- Serves as a clinical leader and systems expert resource.