What are the responsibilities and job description for the Director, Clinical Documentation Improvement Program position at Jobs@UIOWA?
University of Iowa Health Care—recognized as one of the best hospitals in the United States—is Iowa's only comprehensive academic medical center and a regional referral center. More than 12,000 employees, students, and volunteers work together daily to provide safe, quality health care and excellent service for our patients. Simply stated, our mission is: Changing Medicine. Changing Lives.®
UI Health Care seeks a Director for the Clinical Documentation Improvement (CDI) program to provide leadership, direction, and oversight system-wide in developing and implementing clinical documentation improvement processes that maximize efficiency and quality of clinical documentation. The CDI program is responsible for reviewing inpatient medical records to facilitate the accurate representation of the severity of illness. This involves extensive record review, interaction with physicians, HIM professionals, and other ancillary staff. The Director serves as a liaison between clinical care providers, validators/coders and Finance.
This role is responsible for overall leadership, management, and training of the Clinical Documentation Specialists nurses. This position reports directly to the Chief Medical Officer, UI Health Care.
Key Areas of Responsibility:
Apply Process Improvement, Quality Engineering, and Management Engineering Concepts and Methodologies:
- Coordinates documentation improvement & coding audits, providing physician documentation improvement education and providing CFO/Administrators orientation on documentation improvement activities. This individual will be required to make independent decisions regarding documentation for accurate ICD-9-CM / ICD-10-CM-PCS code assignment
- Accountable for CDI successes as demonstrated through various indices which include but not limited to accurate Severity of Illness (SOI) / Risk of Mortality (ROM) capture rates, Complicating or Comorbid Condition (CC) / Major Complicating or Comorbid Condition (MCC) capture rates, Case Mix Index (CMI) analysis, physician query- response rates, and tracking financial variances
- Institutes strategies that will facilitate effective collaboration between the Director/Manager of Health Information Management, Director/Manager of Utilization Review/Case Manager, Administration and other applicable departments as it relates to clinical documentation improvement
- Develops and maintains the relationships with other departments to facilitate collaboration and achievement of department, hospital and UI Health Care goals
- Promotes inter and intra departmental relations as a steward of Service Excellence.
- Represents the Chief Medical Officer on hospital and UI Health Care subcommittees; chair committees as requested.
- Represents the UI Health Care on various internal and external committees and associations.
Collect and Analyze Data:
- Reviews inpatient medical records prospectively to ensure that the care of the patient is recorded in language the payers can interpret and which accurately depicts the acuity of the patient and resources expended.
- Reviews surgical procedures to ensure documentation is accurate for ICD-10/PCS code assignments.
- Tracks and trends outcomes of queries sent using reports from 3M Health Data Management (HDM) system.
- Reviews data/metrics with providers at Medical staff meetings as well as on an individual basis with a focus on strategies that will drive improvement as it relates to documentation improvement and denials management.
Project Management:
- Manages projects that provide support across the spectrum of documentation improvement from identifying and educating interdisciplinary champions to identifying and implementing process improvement/efficiencies and tracking/auditing of metrics to indicate successes or improvement areas.
- Leads projects to provide onsite support and education to coders, physicians, case managers and administration to ensure improved documentation reflecting the quality of care provided across all departments and interdisciplinary care teams
- Manages multiple projects necessary to promote accurate concurrent documentation from all disciplines (physicians, case managers, nurses, dietitians, wound care specialists etc.) to capture best practice documentation for specific diagnoses
- Ensures successful completion of projects to provide overall improvement of quality and completeness of clinical documentation and directly manages activities related to improving clinical documentation that is consistent with the mission of the organization and the values critical to the future of the organization.
- Develops supporting documents to present to Senior Leadership stakeholders in order to solidify scope, propose additional resources, and update on project schedule/results.
Quality Assurance and Compliance:
- Knowledgeable of legal issues involved in patient care information and exercises considerable judgment relative to compliance and HIPAA issues.
- Works closely with Physician Advisor(s)/Chief Medical Officer(s) on escalated cases to ensure that the appropriate documentation is added to the medical record, collaborating with the inpatient Coding team and Clinical Informatics team and their leadership to ensure adherence to established processes, and providing second level reviews when necessary.
- Evaluates regulatory changes and educate staff appropriately.
Training/Education:
- Create and implement training and development for nursing staff, physicians and mid-level practitioners that addresses documentation issues and variances.
- Teaches and mentors other CDS (Clinical Department Supervisors) on CDI principles and concepts, serving as a resource person to key stakeholders across the organization
- Maintains a climate of learning that promotes educational experiences for all levels of staff in high priority project areas.
Leadership/Supervision, Budget:
- Responsible for providing daily oversight and supervision of CDI Specialists/RN’s
- Participates in the preparation of targeted area budget. Monitors specific budgetary activity to promote cost effectiveness and maintain/increase revenue
- Has regular, reliable, predictable attendance in the performance of essential functions whiles meeting or exceeding expected timelines on performance level as it relates to personnel, budgeting and reporting responsibilities.
Human Resources Administration:
- Hire, develop, and manage the performance of staff; assure staff are compliant with UI policies and procedures.
- Develop and implement policies and practices of a culture that supports staff engagement.
- Hold employees accountable for high performance and high engagement culture by articulating expectations, monitoring performance and providing feedback consistency across areas of responsibility.
- Identifies and provides opportunities for the staff to develop knowledge, skills, and abilities needed to contribute to the success of the department.
Salary structure 6A: https://hr.uiowa.edu/pay/pay-plans/professional-and-scientific-pay-structure
Benefits Highlights: Fringe benefit package including paid vacation; sick leave; health, dental, life and disability insurance options; and generous employer contributions into retirement plans. Complete information regarding the full benefits package may be viewed at: https://hr.uiowa.edu/benefits
Living in the Iowa City area: UI Health Care and the University of Iowa is located along the picturesque Iowa River in Iowa City, a city of some 77,000 people (170,000 in the metro area) regularly ranked as one of the nation’s best places to live. Iowa City is less than four hours from Chicago and within five hours of Minneapolis, St. Louis, and Kansas City, readily accessible via interstate highways and a regional airport 30 minutes away. For more information about Why Iowa? click here.
Qualifications:
Required:
- A master’s degree in a healthcare or related field, or an equivalent combination of education and experience is required.
- 3 – 5 years’ clinical and/or hospital administration experience is required.
- Developmental and administrative experience in a hospital setting is required.
- Demonstrated ability with complex statistical and financial analysis, presentation, and forecasting is required
- Familiarity with medical coding, DRG assignment and/or case management is required.
- Demonstrated excellent written, verbal and interpersonal communication skills; ability to communicate effectively with physicians, nursing staff, and interdisciplinary team members.
- Demonstrated proficiency in Microsoft Office Suite, including Word, Power Point and Excel is required.
- Professional job-related experience fostering or promoting a welcoming and respectful work/academic environment where people of all backgrounds and perspectives feel welcomed and appreciated; or the demonstrated ability to do so is required.
Desirable:
- Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP) is strongly desired.
- Demonstrated ability to collaborate with multidisciplinary teams to drive improvements through change
- Electronic Medical Records experience is desired (EPIC preferred).
- Strong knowledge of the Medicare reimbursement system and coding structures/national coding guidelines and related appropriate chart documentation.
- Demonstrated knowledge of healthcare outcomes and performance improvement initiatives/techniques.
- Experience with hospital quality/safety metrics.
- Experience working at large academic medical centers.
Application Process: To be considered, applicants must upload a cover letter and resume (under the submission of relevant materials) that clearly address how they meet the listed required and desired qualifications of this position.
Job openings are posted for a minimum of 14 calendar days. Applications will be accepted until 11:59 PM on March 27, or on date of closing. Successful candidates will be required to self-disclose any conviction history and will be subject to a criminal background check and credential/education verification.
Up to 5 professional references will be requested at a later step in the recruitment process. For questions, contact Heidi Bodensteiner at heidi-bodensteiner@uiowa.edu
This position is not eligible for University sponsorship for employment authorization.
