Responsible for overseeing clinical documentation teams by ensuring effective and efficient review of physician documentation. This position manages the review processes for complex patients with varying acute and chronic disease states, and develops action plans for improvement. This role also collaborates with multiple entities to coordinate the efficient review and documentation capture of underlying conditions supported by physician review and patient records.
Audits documentation quality to support accurate statistics and reimbursement for all regional acute care facilities.
Maintains team members' personal records.
Works with employee relations on performance issues with team members. Other duties as assigned.
Assists with regional budgets and operates within budgetary targets. Provides training for front line staff to ensure expected outcomes.
Chairs facility-based improvement meetings and provides presentations for physician education.
Monitors computer applications and performs quarterly testing updates as needed.
Develops and monitors implementation of market departmental goals/objectives and oversees the performance improvement process for all acute care facilities.
Supports hospitals' quality operating systems by generating and analyzing data and reports to identify opportunities for continuous growth and improvement.
Develops and implements site facility work plans.
Knowledge, skills, and abilities include broad knowledge of healthcare regulations, the ability to interpret reports and provide education based on results, apply critical thinking and strong organizational skills, extensive knowledge of reimbursement systems; federal, state, and payer-specific regulations and policies pertaining to documentation and coding, excellent communication techniques in oral and written form, knowledge of computers including basic skills in Windows and Outlook, ability to present to management, staff, and business partners, comfortable in a complex and changing healthcare environment, knowledge of medical record investigative review, strong analytical and problem-solving skills, knowledge of ICD-10 coding compliance and regulations, demonstrates knowledge and use of effective quality improvement/change management techniques with the ability to lead the implementation of new models and ensure the goals are achieved, ability to understand major objectives and break them down into meaningful action steps, methodically analyzes and evaluates business problems by defining the challenges, identifying alternatives, and making timely suggestions, project management including the ability to learn and effectively use project management software, proficiency in Office Suite of products particularly Excel and PowerPoint, proficiency or ability to learn Social Media Management, strong interpersonal skills with the ability to communicate and work well with staff at all levels of the organization, in-depth knowledge of clinical and non-clinical hospital operations and continuum of care quality standards and regulations, experience in leadership with multidisciplinary teams.
Education: Bachelor's in nursing, healthcare, or related field or associate of science in nursing [Required]. Master's [Preferred].
Field of Study: Nursing, Healthcare, or related field or Associate of Science in Nursing.
Work Experience: 1+ recent clinical documentation experience [Required]. 2+ leadership experience [Preferred]. 5+ acute care nursing experience with specific medical/surgical, intensive care, post-acute care unit, or emergency department experience. [Required]
Licenses and Certifications: Certified Clinical Documentation Specialist (CCDS) [Required] AND Educational Commission for Foreign Medical Graduates (ECFMG) [Required] OR Physician Assistant (PA) [Required] OR Registered Nurse (RN) [Required] OR Advanced Practice Registered Nurse (APRN) [Required]
Pay Range: $83,699.48 $155,693.55