Clinical Documentation Improvement; CDI Manager

Overview

Hybrid Work Schedule May Be Available After Probationary Period. Must be available for in-person work on a weekly basis.
This Position is Not a Fully Remote Position

EMPLOYER-PAID PENSION PLAN (NEVADA PERS)
• COMPETITIVE SALARY & BENEFITS PACKAGE

Responsible for identification of documentation improvement opportunities related to ICD-10, UHDDS, and CMS. Assists with day-to-day CDI administration and oversight of concurrent query writing process. Collaborates with interdisciplinary teams including but not limited to physicians, Advance Practice Professionals, HIM, Quality Improvement, Coding, and leaders in revenue cycle to ensure accurate and comprehensive documentation that reflects the true clinical picture of the patient.

Identifies strategies through data gathering and analysis of trends to establish recommendations for the sustained work process changes that facilitate complete and accurate clinical documentation. Utilizes clinical expertise and clinical documentation improvement practices as well as facility-specific tools for best practice and compliance with the mission/philosophy of the hospital.

Option 1: Graduation from an accredited school of nursing and five (5) years of clinical nursing experience and three (3) years of clinical documentation improvement experience. Two (2) years of experience in clinical documentation leadership.

Option 2: Physician graduate International MD with 5 years of acute care experience and 1 year Clinical Documentation Improvement (CDI) experience. Two (2) years experience in clinical documentation leadership.

Option 3: Equivalent to a Bachelor’s degree in Health Information Management or Health Information Technology and four (4) years professional coding and abstracting medical records in an acute care hospital. Two (2) years of experience in clinical documentation leadership.

Option 1: Valid license by the State of Nevada to practice as a Registered Nurse and one of the following, Certified Clinical Documentation Specialist (CCDS), Certified Clinical Documentation Specialist-Outpatient (CCDS-O) or Certified Document Improvement Practitioner (CDIP).

Option 2: Certification in one of the following:
Certified Coding Specialist (CCS), Registered Health Information Technician (RHIT), or Registered Health Information Administrator (RHIA), issued by the American Health Information Management Association, Certified Professional Coder (CPC), Certified Professional Coder-Physician-based (CPC-P), and one of the following:
Certified Document Improvement Practitioner (CDIP), Certified Clinical Documentation Specialist (CCDS), Certified Clinical Documentation Specialist-Outpatient (CCDS-O)

Option 3: Equivalent to a Bachelor’s degree in Health Information Management or Health Information Technology and four (4) years professional coding and abstracting medical records in an acute care hospital. Two (2) years of experience in clinical documentation leadership.

Knowledge of: Reimbursement and coding methodologies and guidelines; MS-DRGs, APR-DRGs;
Severity of Illness, Risk of Mortality, Medical Necessity, Core and Quality Measures and impact of Length of Stay; HACs/PSIs; supervisory principles and practices; disease pathophysiology and drug utilization clinical documentation improvement and coding; department and hospital safety practices and procedures; patient rights; infection control policies and practices; handling, storage, use and disposal of hazardous materials; department and hospital emergency response policies and procedures;

age-specific care practices.

Skill in: Assigning and monitoring the work of others; evaluating quality control; implementing process including assessment, planning, implementation and evaluation; supervising and training staff; developing and monitoring budgets; developing staffing plans; performing data analysis; holding in complete confidence all information acquired from medical records and physicians; interpreting patient charts to determine whether care given was appropriate and properly documented; interpreting regulations and…