JOB SUMMARY: The Clinical Documentation Improvement and Utilization Review Director is a leader responsible for the strategic and operational planning, design, implementation, and oversight of Avera Health's system-wide and standardized Clinical Documentation Improvement (CDI) and Utilization Review (UR) Programs.
· Program Standardization: Ensures standardization throughout the existing CDI and UR programs according to industry leading practices. Develops and maintains organization-wide policies and guidelines that provide structure for the individual CDI and UR Programs.
· Strategic Planning: Provides strategic planning and direction for the development and enhancement of both programs services throughout Avera Health Services markets. Develops collaborative relationships with internal resources, consultants, auditors, payers and physician champions to develop and achieve the established plan.
· Program Governance: Works with Avera leadership to implement a CDI and UR governance structure responsible for achieving clinical and operational excellence, and expected deliverables in relation to the CDI and UR Programs. Provides leadership support and integrates with other departments/programs such as HIM/Coding, business office and clinical care departments.
· Metrics and Reporting: Develops meaningful scorecards, dashboard metrics, peer group comparisons, and service specific data that are actionable. Implements tracking tools to benchmark against best practices, to maintain forward momentum, and to establish timelines for actions.
· CDI and UR Program Goals: Establishes, reviews, and updates short- and long-term system CDI and UR goals. Ensure alignment of goals with Avera Annual Quality Plan. Monitor and track the progress of both programs, and report findings to executive leadership.
REQUIRED EDUCATION and/or EXPERIENCE:
· Bachelor's degree required. Master's within Nursing or RHIA preferred.
· Certified Clinical Documentation Specialist (CCDS) or Certified Clinical Documentation Improvement Practitioner (CDIP) credential required or Three (3) plus years of experience as a CDI management experience in an acute care hospital setting, with the intent to obtain certification within two (2) years.
· Clinical and hospital coding knowledge (i.e., APR-DRG, MS-DRG, Medicare, Medicaid & Managed Care) in order to design and develop strategies to yield improvements to documentation that will improve overall patient quality, capture severity, assess acuity and determine risk of mortality.
· Expertise in the area of clinical documentation to ensure the completeness of the patient records using multidisciplinary and interdisciplinary teams.
· Working knowledge of computer-assisted coding and CDI systems preferred.
· Exceptional project management and organizational skills, with the demonstrated ability to drive multiple concurrent projects to completion in a complex, consensus-oriented environment.
· Experience standardizing CDI and/or UR processes and implementing best-practices.
· Knowledge of health care delivery system and/or healthcare revenue cycle functions.
· Thorough knowledge of treatment programs and philosophy, administrative policies and procedures across Avera Health facilities.
· Broad knowledge of insurance regulations and Medicare and Medicaid guidelines.
· Demonstrated competency in building and working in teams and ability to communicate with all levels of the organization.
REQUIRED CERTIFICATION, LICENSURE and/or REGISTRATIONS
This position requires a valid driver's license and that the employee is insurable by the Avera Health automobile liability insurance carrier.
Obtain Certified Clinical Documentation Specialist (CCDS) or Certified Clinical Documentation Improvement Practitioner (CDIP) credential within 2 years of start date.
Applicants who are not certified are able to sit for the national exam within one year of employment.