Oversees and coordinates the facilitation of the Clinical Documentation Improvement (CDI) services at DCH. Facilitates day to day operations of the CDI team across the DCH System and serves as a resource to hospital and medical staff to assure improvement with documentation and compliance with regulatory agency standards.

1. Establishes, supervises, approves, and evaluates staffing levels, assignments, skills, learning needs and deployment of clinical documentation staff.
2. Monitors patterns of medical staff non-compliance with the CDI program, and target them for intervention, working with the CDI Manager and physician advisor to provide ongoing physician education related to documentation.
3. Participates in denial & appeal management
4. Mortality reviews
5. PEPPER Report reviews
6. Works collaboratively with the Health Information Management (HIM) Coding Manager to educate on CDI best practices and provide education to CDI and Coding teams.
7. Serves as a contact person for the physicians and hospital staff in issues pertaining to Clinical Documentation Improvement.
8. Participates in departmental and hospital committees and taskforces and conducts studies as necessary to demonstrate improvement in the DCH CDI processes.
9. Work with CDI and Coding Mangers to Identifies DRG groups that have a significant variance and/or opportunity for improvement and target them for education and improvement.
10. Conducts concurrent and retrospective reviews to audit the accuracy of CDI team.
11. Serves as HIM Supervisor-on-call in rotation with other HIM supervisory staff.
12. Oversees the design, implementation and reporting related to assigned clinical documentation improvement activities.
13. Maintains thorough and up-to-date records for all assigned activities.

DCH Standards:

• Maintains performance, patient and employee satisfaction and financial standards as outlined in the performance evaluation.
• Performs compliance requirements as outlined in the Employee Handbook
• Must adhere to the DCH Behavioral Standards including creating positive relationships with patients/families, coworkers, colleagues and with self.

• Performs essential job functions in a manner that ensures the safety of patients, visitors and employees.
• Identifies and reduces unsafe practices that may result in harm to patients, visitors and employees.
• Recognizes and takes appropriate action to reduce risks and hazards to promote safety for patients, visitors and employees.

• Requires use of electronic mail, time and attendance software, learning management software and intranet.
• Must adhere to all DCH Health System policies and procedures.
• All other duties as assigned.

1. Associate degree in HIM, Nursing, or related field required. Bachelor degree in HIM, Nursing or related field preferred. 
2. Three years in healthcare field such as clinical care, utilization review, health information, or case management required.
3. Supervisory experience preferred.
4. Five years in healthcare field such as clinical care, utilization review, health information management, or case management preferred.
5. Must have CDI knowledge
6. Must have experience in ICD-10 CM coding
7. Must have knowledge of Medicare and Regulatory Compliance requirements for CDI role
8. Knowledge & experience with electronic medical records and electronic queries & query software
9. Must have advanced knowledge of computers and office productivity software.
10. Must have advanced knowledge of data analysis.
11. Must have excellent verbal and written communication skills.
12. Demonstrates creativity, innovative ideas, problem-solving skills
13. Certification in Clinical Documentation Improvement (CDIP, CCDS) Health Information Management (RHIT, RHIA) or coding (CCS) preferred
14. Must be able to read, write legibly, speak, and comprehend English.

WORKING CONDITIONS

WORK CONTEXT

• Ability to form positive, collaborative relationships with physicians, colleagues, hospital staff, patients, families, and external contacts.
• Ability to provide guidance and direction to subordinates, including performance standards and monitoring performance.
• Ability to encourage and build mutual trust, respect, and cooperation among team members.
• Ability to communicate with people outside the organization and represent the organization to the public, government, and other external sources.
• Ability to work independently or within a team structure.
• May be exposed to environmental cleaning chemicals

PHYSICAL FACTORS

• Requires Light work. Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of force constantly to move objects. If the use of arm and/or leg controls requires exertion of forces greater than that for sedentary work and the worker sits most of the time, the job is rated for light work.

• Ability to tolerate prolonged periods of sitting or standing and/or walking.
• Ability to reach reasonable distances to handle equipment.
• Good manual and finger dexterity.
• Must be able to perform the duties with or without reasonable accommodation.
• Hearing and vision must be normal or corrected to within normal range.

Physical presence onsite is essential.