Director of Clinical Optimization

Director Of Clinical Optimization

The Director of Clinical Optimization is responsible for leading initiatives that improve the accuracy and completeness of clinical documentation, severity of illness (SOI), risk of mortality (ROM), case mix index (CMI), hierarchical condition category (HCC) capture, and risk adjustment across the continuum of care. This leader serves as the operational bridge between providers, Clinical Documentation Integrity (CDI), Coding, Case Management, Population Health, Finance, Quality, and Information Technology to ensure documentation accurately reflects the complexity of patients while supporting quality outcomes, value-based reimbursement, and regulatory compliance. The Director develops a comprehensive clinical optimization strategy focused on inpatient, outpatient, ambulatory, and population health documentation. The role ensures that every patient encounter accurately reflects the true complexity of care, resulting in: Improved quality outcomes, more accurate risk-adjusted performance, enhanced reimbursement integrity, stronger value-based performance, reduced documentation-related denials, better physician engagement, improved patient care through accurate clinical representation.

Minimum Qualifications

Education, Certification, and/or Licensure:

• Bachelor of Science degree in Nursing or related healthcare field required.
• Current Registered Nurse license issued by the state in which services will be provided or current multi-state Registered Nurse license through the enhanced Nurse Licensure Compact (eNLC). Other clinical licensure may be considered.
• Obtain certification in Basic Life Support within 30 days of hire date.

Experience:

• Seven (7) years of progressive healthcare leadership.
• Experience in CDI, Coding, Quality Improvement, Population Health, Value-Based Care, Physician Engagement, Clinical Documentation, and Hospital Operations.

Preferred Qualifications

Education, Certification, and/or Licensure:

• Master's degree (MSN, MHA, MBA, MPH, or equivalent) preferred.
• Preferred Certifications to include; Association of Clinical Documentation Integrity Specialists Certified Clinical Documentation Specialist (CCDS), American Health Information Management Association Certified Coding Specialist (CCS), American Academy of Professional Coders Certified Professional Coder (CPC), National Association of Healthcare Quality Certified Professional in Healthcare Quality (CPHQ), Lean Six Sigma Green Belt or Black Belt, Certified Risk Adjustment Coder (CRC).

Core Duties and Responsibilities

The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.

• Developing and overseeing the Clinical Optimization Program.
• Improve documentation supporting Severity of Illness (SOI), Risk of Mortality (ROM), Case Mix Index (CMI), Expected Mortality, and Expected Length of Stay.
• Partner with CDI and Coding to identify documentation opportunities.
• Standardizing physician documentation best practices across all hospitals.
• Lead Risk Adjustment & HCC initiatives to improve HCC capture, RAF accuracy, Chronic disease documentation, Annual wellness documentation, Risk adjustment education, Medicare advantage documentation, and Ambulatory coding optimization.
• Collaborate with Primary Care, Specialists, Population Health, Value-Based Care, and Care Management.
• Partner with Quality teams to improve Vizient Mortality, Readmissions, Patient Safety Indicators, Hospital Acquired Conditions, CMS Star Measures, Quality Blue, Peak Health, Value Based Purchasing, DPP measures, MSSP/ACO quality metrics.
• Ensure documentation appropriately reflects patient acuity for quality benchmarking. Work on Pre-bill HAC, PSI, and other reviews.
• Develop physician engagement strategies including Documentation education, Specialty-specific scorecards, Provider dashboards, Peer comparison reports, One-on-one physician coaching, medical staff presentations, new provider onboarding.
• Partner with physician advisors and medical staff leadership.
• Monitor regional performance including Case Mix Index, SOI/ROM, Mortality Index, observed vs Expected Mortality, Readmission Index, HCC capture rates, RAF scores, Query response rates, Documentation opportunities, Clinical validation trends, Denial trends.
• Develop executive dashboards for leadership.
• Partner with Information Technology and Analytics to optimize Ambulatory Documentation Initiative, Annual HCC Refresh Campaign, Clinical Documentation Scorecards, Executive Documentation Dashboard.
• The Director will be accountable for improvements in Case Mix Index (CMI), Severity of Illness (SOI), Risk of Mortality (ROM), Expected Mortality, Observed/Expected Mortality, Vizient rankings, HCC Capture Rate, RAF Accuracy, Provider Query Response Rate, Query Agreement Rate, Readmission Index, Length of Stay Index, Documentation-related denials, Coding accuracy, Clinical validation success rate.

Physical Requirements:

• The National Institute for Occupational Safety and Health recommends minimizing the need for employees to manually lift patients and limit safe patient handling to 35 pounds. All transfers, lifts and re-positioning will be completed utilizing the lift equipment and/or other patient handling aids as indicated by the patient's profile and appropriate algorithms.
• Heavy/Hard work: Work requires strength and/or stamina, lifting, moving, stooping, reaching, standing, walking, and carrying materials and equipment weighing 40+lbs.

Working Environment:

• The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Skills and Abilities:

• Ability to promote a positive work environment with a team approach to patient and families.
• Ability to actively listen and promote shared governance within the program area.
• Ability to participate in continuing education and training.
• Conflict resolution skills.
• Strong interpersonal and communication skills.

Additional Job Description:

Scheduled Weekly Hours: 40

Shift: Exempt/Non-Exempt: United States of America (Exempt)

Company: WH Wheeling Hospital Inc.

Cost Center: 405 WH Quality Management

Address: 1 Medical Park DriveWheelingWest Virginia

Equal Opportunity Employer

West Virginia University Health System and its subsidiaries (collectively "WVUHS") is an equal opportunity employer and complies with all applicable federal, state, and local fair employment practices laws. WVUHS strictly prohibits and does not tolerate discrimination against employees, applicants, or any other covered persons because of race, color, religion, creed, national origin or ancestry, ethnicity, sex (including gender, pregnancy, sexual orientation, and gender identity), age, physical or mental disability, citizenship, past, current, or prospective service in the uniformed services, genetic information, or any other characteristic protected under applicable federal, state, or local law. All WVUHS employees, other workers, and representatives are prohibited from engaging in unlawful discrimination. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, training, promotion, discipline, compensation, benefits, and termination of employment.