Clinical Documentation Specialist

Clinical Documentation Improvement Manager

It's more than a career, it's a calling.

WI-REMOTE

Worker Type: Regular

Job Summary: Oversees and manages the daily operations and activities of the regional Clinical Documentation Improvement (CDI) program. Promotes consistent and standardized operations and documentation across the network. Builds and maintains productive inter/intra departmental and vendor work relationships to optimize operations.

Job Responsibilities and Requirements:

PRIMARY RESPONSIBILITIES

• Manages the daily operations and resources of assigned Clinical Documentation Improvement (CDI) team, including the development and monitoring of strategic operating goals, objectives, and data analysis; and report operational performance, justification, and/or corrective action. Provides on-going support of CDI with extensive collaboration with physicians, nursing, coding, quality, and leadership.
• Facilitates improvements to clinical documentation through chart review and educational training sessions (with CDI Educator), which could be performed onsite, with physicians and/or other clinical professionals. Initiates corrective actions to resolve any problem areas identified between CDI and any other areas of the organization.
• Collaborates with CDI educator for regional education. Provides ongoing clinical documentation management program education for new staff, including new clinical documentation registered nurses, physicians, nurses, and allied health professionals. Participates in the direction and education of all phases of the clinical documentation process.
• Supports and implements technologies designed to improve and/or ensure the accurate depiction of clinical services, patients severity of illness, and risk of mortality.
• Conducts audits on CDI reviews against quality, coding, and mortality. Provides feedback to staff and CDI educator and director. Reports monthly CDI metrics regarding KPIs and staff productivity. Strengthens technical coding practices and clinician documentation by reviewing patient records with flagged complications to ensure coding accurately reflects the patients clinical course and complexity to validate accurate risk-adjustment for administrative metrics used in government incentive/penalty programs.
• Collaborates with interdisciplinary teams including physicians, nurse practitioners, physicians assistants, and the department managers for revenue integrity, coding and data quality, case management and health information management. Demonstrate leadership and management skills to promote effective and efficient review of physician documentation and the medical record.
• Communicates with assigned regional/ministry physician leaders. Participates in monthly medical management meetings to report CDI metrics and act as subject matter expert for inquiries.
• Recruits, engages, develops, leads, and manages assigned staff.
• Performs other duties as assigned.

EDUCATION

• Graduate of accredited school of nursing or education equivalency for licensing

EXPERIENCE

• Two years' acute hospital experience or surgical area as a clinical nurse
• Three years' clinical documentation specialist
• Two years' demonstrated progressive leadership experience

PHYSICAL REQUIREMENTS

• Frequent lifting/carrying and pushing/pulling objects weighing 0-25 lbs.
• Frequent sitting, standing, walking, reaching and repetitive foot/leg and hand/arm movements.
• Frequent use of vision and depth perception for distances near (20 inches or less) and far (20 feet or more) and to identify and distinguish colors.
• Frequent use of hearing and speech to share information through oral communication. Ability to hear alarms, malfunctioning machinery, etc.
• Frequent keyboard use/data entry.
• Occasional bending, stooping, kneeling, squatting, twisting and gripping.
• Occasional lifting/carrying and pushing/pulling objects weighing 25-50 lbs.
• Rare climbing.

REQUIRED PROFESSIONAL LICENSE AND/OR CERTIFICATIONS

State of Work Location: Illinois

• Registered Professional Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR)

State of Work Location: Missouri

• Registered Nurse (RN) Issued by Compact State
• Or
• Registered Nurse (RN) - Missouri Division of Professional Registration

State of Work Location: Oklahoma

• Registered Nurse (RN) Issued by Compact State
• Or
• Registered Nurse (RN) - Oklahoma Board of Nursing (OBN)

State of Work Location: Wisconsin

• Registered Nurse (RN) Issued by Compact State
• Or
• Registered Nurse (RN) - Wisconsin Department of Safety and Professional Services

Work Shift:

Day Shift (United States of America)

Job Type:

Employee

Department:

8746010033 Sys Clinical Documentation Improvement

Scheduled Weekly Hours:

40

Benefits:

• Paid Parental Leave: we offer eligible team members one week of paid parental leave for newborns or newly adopted children (pro-rated based on FTE).
• Flexible Payment Options: our voluntary benefit offered through DailyPay offers eligible hourly team members instant access to their earned, unpaid base pay(fees may apply) before payday.
• Upfront Tuition Coverage: we provide upfront tuition coverage through FlexPath Funded for eligible team members.

SSM Health is an equal opportunity employer. SSM Health does not discriminate on the basis of race, color, religion, national origin, age, disability, sex, sexual orientation, gender identity, pregnancy, veteran status, or any other characteristic protected by applicable law.