[Hiring] Director, Clinical Documentation Integrity @University of Miami

Role Description

The Director, Clinical Documentation Improvement is responsible for progress towards goals and objectives for the Health System’s Clinical Documentation Improvement program, in collaboration and as directed by the Clinical Documentation leadership team. Based on System-wide initiatives and hospital goals, the Director will develop annual CDI workplans and report completed activities to CMO, CNO, CFO, and Quality leaders. Responsibilities include:

• Identify Clinical Documentation improvement issues and foster excellent communication with physicians, nurses, coding, and other members of the health care team to resolve such issues.
• Assist CDI team with educational needs, problem resolution, time management, and critical thinking skills development.
• Implement clinical skills activities within established clinical and preceptorship models, monitor data trends, and implement educational strategies to ensure compliance with quality standards.
• Collaborate with the Professional Development Department to develop and provide new hire CDI onboarding and department-specific orientation programs and competencies for new CDI Specialists.
• Maintain all department training materials, tools, and/or records.
• Develop and maintain department’s web-based collaborative platforms with education topics, performance outcomes by facility, and key areas for CDI.
• Perform quality documentation audits, including chart review and query compliance of patient records.
• Provide mentoring and ongoing feedback to the CDI Team.
• Engage physicians/providers on CDI topics and attend monthly service line meetings.
• Develop and present key CDI topics at all service line meetings.
• Monitor CDI performance and track CDI team knowledge through bi-annual assessment tests.
• Develop and maintain CDI assessment tests and education around topics missed.
• Provide education to the CDI team related to annual regulatory updates and changes.
• Collaborate with Leadership and Medical Directors in the development and delivery of specialty-specific education to physicians, departments, and specialties.
• Evaluate second level review audits for areas of opportunity and develop education sessions to enhance CDI team performance and/or physician documentation.
• Represent the CDI team at various meetings as a clinical documentation improvement subject matter expert.
• Coordinate with other departments regarding CDI initiatives to ensure efforts are synchronized, consistent, and effective.
• Participate in performance improvement activities related to the operational processes for the Documentation Improvement Team.
• Develop collaborative relationships and promote teamwork with co-workers, physicians, and other departments.
• Collaborate with external CDI consultants to identify education gaps or opportunities.
• Incorporate protocols and standards of care into daily practice.
• Conduct initial and follow-up concurrent reviews on targeted admissions for opportunities to clarify documentation.
• Coordinate with coding, HIM, Care Management, and other departments to achieve accurate patient records.
• Review medical records concurrently for documentation supported by clinical indicators.
• Perform thorough chart reviews to identify co-morbidities/complications and document appropriately.
• Display leadership and accountability, serving as coach and role model.
• Communicate effectively, timely, and in an open and honest manner.
• Display mental and emotional effort required to function effectively in a dynamic environment.
• Promote continuous improvement of workplace safety and environmental practices.
• Ensure compliance with all institutional policies and procedures.
• Maintain professional knowledge by participating in continuing education programs, conferences, and workshops.
• Adhere to University and unit-level policies and procedures.

Qualifications

• Bachelor’s degree in Healthcare Administration, Health Information Management, Informatics, Nursing, Leadership, Education, or related field; Master’s degree is highly preferred.
• Current FL RN License; FMG (MD) with extensive clinical and CDI experience will be considered.
• Must maintain current certification:
  • Certified Documentation Specialist (CCDS);
  • Clinical Documentation Improvement Professional (CDIP);
  • Certified Professional Coder (CPC);
  • Certified Coding Specialist (CCS).

Requirements

• Five (5) years of clinical experience in a hospital setting; prior CDI experience required.
• Thorough knowledge of ICD-9-CM, ICD-10-CM/PCS, APR DRG and MS DRG, Mortality, PSI, and HAC required.

Benefits

• Competitive salaries.
• Comprehensive benefits package including medical, dental, tuition remission, and more.

Company Description

UHealth-University of Miami Health System, South Florida's only university-based health system, provides leading-edge patient care powered by groundbreaking research and medical education at the Miller School of Medicine. As an academic medical center, we serve South Florida, Latin America, and the Caribbean. Our physicians represent more than 100 specialties and sub-specialties, and have more than one million patient encounters each year. Our tradition of excellence has earned worldwide recognition for outstanding teaching, research, and patient care.