LEAD CLINICAL DOCUMENTATION COORD/GME - VALLEY HOSPITAL (FULL-TIME)

Clinical Documentation Integrity Program Manager

Under the supervision of the Regional Manager, CDI manages day-to-day workflow, specifically the operations of the Clinical Documentation Integrity Program for GME and medical staff education. This position is also responsible for providing clinically based concurrent and retrospective review of inpatient medical records to evaluate the utilization and documentation of acute care services. The goal of concurrent review includes facilitation of appropriate physician documentation of care delivered to accurately reflect patient severity of illness and risk of mortality. Specific reviews are determined both internally and by requirements/requests of external payers or regulatory agencies and play a significant role in reporting quality of care outcomes and in obtaining accurate and compliant reimbursement for acute care services.

Qualifications:

• Education: Associate's degree in nursing; bachelor's degree in nursing preferred or a Graduate of a domestic/international school of medicine.
• Experience: For Registered Nurse, a minimum of two (2) years of clinical experience in an acute care setting (critical care, surgical or emergency department nursing preferred), and a minimum of 1-year previous clinical documentation integrity experience (2-3 years of previous clinical documentation integrity experience preferred). Knowledge of the Prospective Payment System and Diagnosis Related Group selection, assignment and optimization are required. For Domestic/International Medical Graduate: A minimum of 1-year previous clinical documentation integrity experience (2-3 years of previous clinical documentation integrity experience preferred). Knowledge of the Prospective Payment System and Diagnosis Related Group selection, assignment and optimization are required. Minimum of 1-year management experience strongly preferred but not required.
• Technical Skills: Computer proficiency to include word processing, databases, and spreadsheets. Familiarity with the operation of basic office equipment. Basic competence in use of electronic health records and other CDI/Coding software applications.
• License/Certification: If Registered Nurse, current RN license in their state of residence. Preferred certifications: CDIP, CCDS, CCS and/or ICD-10 Certification or Trainer designation.
• Other: Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes. Knowledge of age-specific needs and elements of disease processes and related procedures required. Working knowledge of inpatient admission criteria. Medicare reimbursement system and coding systems required. Must possess excellent written and verbal communication skills and critical thinking skills. Ability to work independently in a time-oriented environment is essential.

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