Clinical Documentation Improvement (CDI) Manager

Global Force USA; Las Vegas (NV); On-site; USD 110,000 - 150,000; Full time

Benefits offered by this job

Sign-on bonus

Job summary

Global Force USA seeks a CDI Manager to lead documentation improvement initiatives tied to ICD-10, UHDDS and CMS, and to oversee concurrent query writing and CDI administration.

You will collaborate with physicians, HIM, coding, quality, and revenue-cycle leadership to ensure accurate documentation reflecting the patient’s true condition.

Qualifications

• Experience with ICD-10, UHDDS and CMS requirements.
• Clinical documentation improvement leadership in an acute care setting.
• Ability to analyze data to identify documentation gaps and opportunities.

Responsibilities

• Identify documentation improvement opportunities related to ICD-10, UHDDS and CMS.
• Oversee day-to-day CDI administration and query writing process.
• Collaborate with physicians, HIM, coding and revenue-cycle leaders to ensure accurate documentation.
• Analyze data and trends to recommend sustained process changes.

Education

RN with CCDS

MD with acute care CDI

HIM/HIT degree + 4 yrs coding

Job description

Clinical Documentation Improvement (CDI) Manager

Sign on bonus up to $15,000.

Position Summary

Responsible for identification of documentation improvement opportunities related to ICD-10, UHDDS, and CMS. Assists with day‑to‑day CDI administration and oversight of concurrent query writing process. Collaborates with interdisciplinary teams including but not limited to physicians, advanced practice professionals, HIM, quality improvement, coding, and revenue‑cycle leaders to ensure accurate and comprehensive documentation that reflects the true clinical picture of the patient. Identifies strategies through data gathering and analysis of trends to establish recommendations for the sustained work process changes that facilitate complete and accurate clinical documentation. Utilizes clinical expertise and clinical documentation improvement practices as well as facility‑specific tools for best practice and compliance with the mission and philosophy of the hospital.

Education and Experience

• Option 1: Graduation from an accredited school of nursing, five (5) years of clinical nursing experience, and three (3) years of clinical documentation improvement experience. Two (2) years of experience in clinical documentation leadership.
• Option 2: Physician graduate International MD with 5 years of acute care experience and 1 year of CDI experience. Two (2) years of experience in clinical documentation leadership.
• Option 3: Equivalent to a Bachelor’s degree in Health Information Management or Health Information Technology and four (4) years of professional coding and abstracting medical records in an acute care hospital. Two (2) years of experience in clinical documentation leadership.

Licensing and Certification Requirements

• Option 1: Valid license by the State of Nevada to practice as a Registered Nurse and one of the following: Certified Clinical Documentation Specialist (CCDS), Certified Clinical Documentation Specialist – Outpatient (CCDS‑O), or Certified Document Improvement Practitioner (CDIP).
• Option 2: Certification in one of the following: Certified Coding Specialist (CCS), Registered Health Information Technician (RHIT), or Registered Health Information Administrator (RHIA) issued by the American Health Information Management Association; Certified Professional Coder (CPC), Certified Professional Coder‑Physician‑Based (CPC‑P); and one of the following: Certified Document Improvement Practitioner (CDIP), Certified Clinical Documentation Specialist (CCDS), or Certified Clinical Documentation Specialist – Outpatient (CCDS‑O).

Knowledge, Skills, and Abilities

Knowledge of: Reimbursement and coding methodologies and guidelines; MS‑DRGs, APR‑DRGs; Severity of Illness, Risk of Mortality, Medical Necessity, core and quality measures and impact of length of stay; HACs/PSIs; supervisory principles and practices; disease pathophysiology and drug utilization; clinical documentation improvement and coding; department and hospital safety practices and procedures; patient rights; infection control policies and practices; handling, storage, use and disposal of hazardous materials; department and hospital emergency response policies and procedures; age‑specific care practices.

Skill in: Assigning and monitoring the work of others; evaluating quality control; implementing processes, including assessment, planning, implementation, and evaluation; supervising and training staff; developing and monitoring budgets; developing staffing plans; performing data analysis; holding in complete confidence all information acquired from medical records and physicians; interpreting patient charts to determine whether care given was appropriate and properly documented; interpreting regulations and standards for others; writing reports, meeting minutes and other technical documents; analyzing statistical and other quantitative data; critical thinking; conflict management; dealing with departmental issues involving self or other employees in professional, forthright, and impartial manner; applying investigative and interviewing techniques; communicating with a wide variety of people from diverse socio‑economic and ethnic backgrounds under stressful conditions; establishing and maintaining effective working relationships with all personnel contacted in the course of duties; efficient, effective and safe use of equipment.

Physical Requirements and Working Conditions

Mobility to work in a typical clinical setting, including stamina to stand and/or sit for extended periods of time, strength to examine and treat varied individuals, vision to use standard office equipment and read printed materials and a computer screen, and hearing and speech to communicate effectively in both oral and written forms. Strength and agility to exert up to 100 pounds of force occasionally, and/or up to 50 pounds of force frequently to move objects. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this classification.