The Clinical Document Improvement Specialist Manager - is responsible for providing CDI program oversight and day to day CDI implementation of processes related to the concurrent review of the clinical documentation in the inpatient medical record of Optum 360 clients' patients. The goal of LCDS oversight and practice is to support the CDI manager function by providing staff oversite, serve as an additional resource as well as perform CDI role function. The Manager will assure via assessment, and teaching staff and providers the technical accuracy, specificity, and completeness of provider clinical documentation, and to ensure that the documentation explicitly identifies all clinical findings and conditions present at the time of service.
This position collaborates with CDI Director, providers and other healthcare team members to make improvements that result in accurate, comprehensive documentation that reflects completely, the clinical treatment, decisions, and diagnoses for the patient. The CDS utilizes clinical expertise and clinical documentation improvement practices as well as facility specific tools for best practice and compliance with the mission/philosophy, standards, goals and core values of Optum 360. This position does not have patient care duties, does not have direct patient interactions, and has no role relative to patient care.
Travel is required between facilities and may be required for meetings at other facilities
Primary Responsibilities: - Conducts chart audits, quality audit and KPI audits
- Conducts CDI Manager with running reports, attends on site meetings as directed
- Oversees CDI staff training and orientation
- Overseas and leads workflow for CDI staff
- Develops physician teaching and on-site presentations
- Assist CDI Director with projects or tasks as needed
- Timecard approval
- Coaching
- Evaluations
- Other duties as assigned
- Communicates performance expectation of leadership to staff level CDI staff
- Oversee that CDI staff are providing expert level review of inpatient clinical records within 24-48 hours of admit; identifies gaps in clinical documentation that need clarification for accurate code assignment to ensure the documentation accurately reflects the severity of the patient condition and acuity of care provided
- Ensures and oversee daily follow-up communication with providers regarding existing clarifications to obtain needed documentation specifically
- Provides expert level leadership for overall improvement in clinical documentation by providing proficient level review and assessment, and effectively articulating recommendations for improvement, and the rational for the recommendations
- Actively communicates with providers at all levels, to clarify information and to communicate documentation requirements for appropriate diagnoses based on severity of illness and risk of mortality
- Performs regular rounding with unit-based physicians
- Provides face-to-face educational opportunities with physicians.
- Provides complete follow-through on all requests for clarification or recommendations for improvement
- Leads the development and execution of physician education strategies resulting in improved clinical documentation
- Ensures timely feedback to providers regarding clinical documentation opportunities for improvement and successes
- Ensures effective utilization of the CAC tool, ensuring documentation of all verbal, written, electronic clarification activity
- Utilizes only the Optum360 approved forms, whether paper or electronic
- Proactively develops a reciprocal relationship with the HIM Coding Professionals
- Coordinate and conduct regular meetings with HIM Coding Professionals to monitor retrospective query rate and address issues
- Engages and consults with Physician Advisor when needed, per the escalation process, to resolve provider issues regarding answering clarifications and participation in the clinical documentation improvement process
- Actively engages with Care Coordination and the Quality Management teams
You9ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
Required Qualifications:- 5+ years of acute care hospital clinical RN experience OR Medical Graduate with CDI experience and CDI certification (CCDS, CDIP)
- 2+ years of experience communicating & presenting to Physicians
- Proficiency using a PC in a Windows environment, including Microsoft Word, Excel, Power Point and Electronic Medical Records
- Ability to work in Chandler, AZ
Preferred Qualifications:- CCDS, CDIP or CCS certification
- People management experience
- Experience in Clinical Documentation Improvement
- CAC experience (Computer Assistant Coding)
Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you9ll find a far-reaching choice of benefits and incentives. The salary for this role will range from $91,700 - $163,700 annually based on full-time employment. We comply with all minimum wage laws as applicable.
