Director of Clinical Documentation Integrity

Johns Hopkins Medicine; Baltimore (MD); On-site; USD 90,000 - 130,000; Full time

Job summary

A prominent health system seeks a Clinical Documentation Integrity Director to lead a team focused on improving clinical documentation quality and ensuring compliance with healthcare standards. The ideal candidate will have a baccalaureate degree in Nursing or an AMA-approved Physician Assistant program, along with significant experience in quality improvement and clinical documentation. Certification as a Clinical Documentation Specialist is highly preferred. This role requires collaboration with various departments to enhance workflows and reporting requirements.

Qualifications

• 10+ years of experience in quality improvement, medical record administration, or clinical documentation.
• 2 years of management experience required.
• Familiar with all government health care reimbursement systems.

Responsibilities

• Oversee the CDI shared service team and maintain quality standards.
• Identify opportunities to improve clinical documentation quality.
• Collaborate with finance and quality staff to meet reporting requirements.

Skills

Clinical documentation

Quality improvement

Coding

Staff management

Education

Baccalaureate degree in Nursing or AMA approved Physician Assistant program

Job description

The JHHS Clinical Documentation Integrity Director (CDI) is responsible for the oversight of the CDI shared service team that is comprised of assistant directors, managers, Registered Nurses (RN) and/or Health Information Professionals in addition to the JHHS CDI Educator. The director acts as a systems expert on matters related to physician clinical documentation, coding, risk adjustment, education and reimbursement processes in working towards agreed upon quality and productivity targets for the health system. This role identifies opportunities to improve clinical documentation quality through process review, performance/quality, and productivity reporting, and works with VPMAs, Functional Unit Administrators, Directors, and others to implement improved process and enhancements. Works in collaboration with finance and quality staff along with other departments and system hospital staff to design workflow and requirements that meet reporting, coverage, and quality review requirements.

Reports to the Executive Director of Regulatory Finance Informatics & Clinical Analytics of the Johns Hopkins Health System.

Qualifications

Requires successful completion of an accredited program: requires Baccalaureate degree from an accredited School of Nursing, OR requires successful completion of an AMA approved Physician Assistant program

10 years of experience in the field of quality improvement, medical record/health information administration, acute care, clinical documentation and/or coding preferred. 2 years of staff management experience required at minimum if past experience is complemented by experience in inpatient, outpatient, compliance, medical necessity, charge master coding quality improvement, or clinical documentation improvement.

• 7 years in clinical documentation preferred
• Be familiar with all government health care reimbursement systems
• Familiarity with Quality Programs
• Coding experience preferred

Required Licensure/Certification

RN: Must possess current licensure to practice as RN in State of Maryland or another state that participates in the Nurse Licensure Compact. or

PA: Must possess current licensure to practice as a PA by the Maryland Board of Physicians. Board certified by the National Commission on Certification of Physician Assistants (NCCPA) or

MD/DO: an active medical license is required; board certification preferred. Experience in Clinical Documentation Integrity strongly preferred.

Certified Clinical Documentation Specialist (CCDS) obtained through the Association of Clinical Documentation Improvement Specialists (ACDIS) and/or Certified Documentation Improvement Practitioner (CDIP) obtained through the American Health Information Management Association (AHIMA) highly preferred. Must obtain CCDS certification within 6 months of hire, if not currently certified.