What are the responsibilities and job description for the Manager, Clinical Documentation Integrity position at Adventist Health?
Located in the metropolitan area of Sacramento, the Adventist Health corporate headquarters have been based in Roseville, California, for more than 40 years. In 2019, we unveiled our WELL-certified campus - a rejuvenating place for associates systemwide to collaborate, innovate and connect.
Whether virtual or on campus, Adventist Health Roseville and shared service teams have access to enjoy a welcoming space designed to promote well-being and inspire your best work.
Job Summary:
Serves as a working manager for team or work group at multiple sites requiring travel between sites. Provides day-to-day oversight of clinical documentation integrity specialists (CDIS) including managing associates, hiring, and orienting new CDIS staff. Completes performance reviews on an annual basis. Evaluates and assesses medical records of patients. Serves as second level reviewer for all cases with unanswered queries being considered for escalation to Physician Champion/CMO, and aids in the escalation and approach for the case. Acts as a liaison between department sites. Assist with quality assurance activities for the site and CDI department as directed by CDI Leadership. Audits work of CDIS employees for accuracy, productivity, and quality standards. Proactively identifies issues or trends and proposes solutions. Communicates issues or concerns with site CDI operations to system CDI leadership. Participates in performance improvement/action plan activities as needed to assure all CDIS employees are meeting or exceeding performance expectations. Produces, analyzes, and distributes reports to leadership. Works with providers for improved documentation. Provides guidance to staff within latitude of established work area and policies. Runs program(s) with moderate budget/impact.
Job Requirements:
Education and Work Experience:
- Bachelor’s Degree or equivalent combination of education/related experience: Required
- Master's Degree: Preferred
- Four years' clinical documentation improvement experience: Required
- Three years' clinical experience: Required
- Leadership experience: Preferred
Licenses/Certifications:
- Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP): Required
- Current licensed RN, Medical provider or equivalent: Required
- Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner Certificate (DIP): Required
Essential Functions:
- Performs audits and education on clinical documentation integrity specialists (CDIS) records including the evaluation and assessment of medical records of patients, looking for severity of an illness, the accuracy of the clinician's documentation, coding requirements and documentation of important medical details to ensure the overall quality and completeness of clinical documentation of the patient medical record.
- Educates CDIS employees on how better to perform duties listed above and other CDIS related information and maintaining their key performance metrics (KPIs). Contributes to staff evaluations and maintains good relationships with staff while managing their performance. Participates in hiring new CDIS staff, orientating staff, sets work assignments, work schedules and has input on the job status of all associates. Produces, analyzes and distributes reports to leadership.
- Analyzes and interprets medical records, reports and clinical documentation. Makes presentations about CDI performance to senior leadership at site. Balances small projects while maintaining workload.
- Keeps abreast of regulatory changes related to documentation, coding and communicate these changes to appropriate staff. Follows documentation guidelines and legal requirements to ensure compliance with federal and state regulatory bodies. Reviews quality of medical record and communicates when conflicting data are found. Serves as an escalation contact for clinical documentation specialists to assist in resolving conflict. Works with appropriate Physician Advisors when escalations arise.
- Acts as a liaison between the medical staff and the coding department. Works collaboratively with physicians and coding staff to ensure that clinical information in the medical record is present and accurate so that the appropriate clinical severity is captured for the level of service rendered to all patients.
- Performs other job-related duties as assigned.
Additional Details: This position will be primarily remote with required travel to St. Helena, Ukiah, and Mendocino Coast.
Organizational Requirements:
Adventist Health is committed to the safety and wellbeing of our associates and patients. Therefore, we require that all associates receive all required vaccinations, including, but not limited to, measles, mumps, flu (based on the seasonal availability of the flu vaccine typically during October-March each year), COVID-19 vaccine (required in CA, HI and OR) etc., as a condition of employment, and annually thereafter. Medical and religious exemptions may apply.
